Web 2.0 in global health: the road to a culture of sharing

*This article was commissioned for a World Health Organization Bulletin’s issue on Health Communication.

When The Global Fund to fight AIDS, Tuberculosis and Malaria launched MyGlobalFund.org, opening up the communication gates to direct and mostly unfiltered discussions and comments from thousands of health experts and inexpert around the world, it was venturing into uncharted territory. For an international financing institution managing a multi-billion dollar fund to support life-saving programs in 140 countries, going from traditional “top-down” communications to a “bottom-up” or horizontal approach, from fully controlling the message to agreeing to participate in it as an equal member of a larger community, was filled with real and perceived threats.

MyGlobalFund connects people through a series of web collaborative tools and features most commonly referred to as the Participatory Web or Web 2.0 (blogs, networking tools, tagging and rating, RSS feeds, public and private discussion forums, file sharing, etc.). It aims to enable a global conversation to save lives by helping to disseminate knowledge and best practices in the fight against the three pandemics.

Members of the community can use this tool to get what they need from each other rather than from the institution. It may be information about Global Fund processes, support for preparing and drafting funding proposals or for implementing funded grants, ideas to improve one’s own work, or recognition for one’s accomplishments in saving and improving lives.

All visitors can read what members publish but basic (free) registration is required to take full advantage of the platform’s functionalities, i.e. to participate in public discussions on the site or through mailing lists, to search for members who share similar profiles (diseases of interest, languages spoken, geographical location, etc.), to send emails to other members or to start private discussions with them[1]. In-country partners who implement life-saving programs with Global Fund support can also manage their own web pages (blogs) to communicate their progress and challenges.

More than a year into the launch, MyGlobalFund is an operational multilingual platform[2] that generates significant activity thanks to sustained promotional efforts, a growing membership base and the facilitation of several structured discussions.

The Global Fund experience also shows that leveraging the power of online collaboration in health communications is not, for the most part, about technology. The decentralized and non-hierarchical logic of Web 2.0 communications comes with its challenges, which have little in common with managing first-generation corporate websites. It entails institutional change, spending enough resources on staff with the right skills in community management, training and marketing, paying special attention to constantly improving user experience, and showing patience in achieving results.

A new institutional mindset

Getting management support is the first key step in developing institutional projects that rely on Web 2.0. The opportunities generated by a decentralized approach to communication, one that allows people to publish information without going through the usual validation process by peers or hierarchy, may easily be outweighed by the perceived threats. Participatory communications clash with long established processes and rely on technologies and concepts which are new, constantly evolving and may seem threatening.

Bearing this in mind, information sessions took place at the Secretariat to explain what were the objectives of the project, how Web 2.0 technology could support the achievement of these goals and what the Global Fund and the global fight against the 3 diseases might gain from its use[3].

Before any technical solution was considered, we developed the concept using visual aids and mockups that showed what the new site could look like. The Secretariat needed to understand the concepts of Web 2.0, how the new tools could be used to enable health and development professionals to share lessons learned from the implementation of their life-saving programs and how the Global Fund could benefit from them. The focus was not on the tools but on identifying the needs and areas where collective user value could bring about improvements in the fight against disease.

These discussions revealed enthusiasm as well as legitimate concerns. How would we avoid losing control and being left with more communication crises than the Secretariat could manage? How would information be validated? How would we monitor and filter thousands of posts to make sure MyGlobalFund remained the constructive and respectful community it was meant to be? How could we limit spam (unsolicited commercial offers) and ‘noise’ (irrelevant contributions which could deter other participants from participating)? How could we prevent participants from spreading rumours that could damage reputations? What impact would it have on our workload? How could the expected high volume of user-generated content be made accessible in a non-chaotic, logical and structured way?

With support from the legal team and in-house expertise in IT law, we reviewed potential threats, identified possible safeguards and drafted a disclaimer[4] and basic code of conduct[5]. In addition to approving the initiative, the Executive Management issued a policy encouraging staff members to actively participate in MyGlobalFund discussions under a few basic conditions[6].

This initial institutional backing was most definitely facilitated by three factors. The Global Fund doesn’t have long established processes, including in the field of communications. This new decentralized and democratic mode of communication is in line with its founding principles of partnership, country ownership and transparency. And more importantly, the need to have a permanent online meeting place and communication platform had regularly been expressed by implementers at Global Fund regional meetings, by participants in the Partnership Forum[7] and by academics[8].

Learning to communicate

Promotion, training and support, not technology, are the most vital components of any successful Web 2.0 project. Without adequate resources in terms of qualified personnel and time, most online communities fail[9]. MyGlobalFund is supported by a multilingual four-member facilitation team. The bulk of its initial efforts went into promoting the new site both online, through several mailing lists, and offline, in various Global Fund regional meetings and related events. As of early 2009, MyGlobalFund.org counted about 4,000 members, people who had registered and completed an online profile. The platform had been used to hold several thematic discussions, such as the e-Forum, a six-month consultation process which drew more than 2,000 contributions from 500 participants in over 100 countries[10].

This promotion and relationship building work is crucial in quickly attracting the critical mass of members who will generate enough activity to make the community a place worth visiting and contributing to. Indeed, studies show that only 9 percent of members of online communities contribute content occasionally, while the vast majority are passive users, visiting and reading content but not actively participating in exchanges[11]. In the case of professional communities discussing technical issues, active participation may be slightly higher and more focused[12], although the Global Fund experience confirms the general rule observed in most online forums[13].

Launching an online toolkit would serve no purpose if its intended users didn’t know how to use it. Communicating in a Web 2.0 era, no matter how simple the tools might seem to some, requires a set of skills and knowledge which should not be underestimated. Concepts such as blogs, tagging, rating, RSS feeds and wikis are not fully grasped by most regular internet users, and much less by occasional ones. Unlike the younger audiences that make up the most popular Web 2.0 communities[14], the public health experts targeted through MyGlobalFund enjoy varying levels of web and computer literacy.

In parallel with their promotional work, a critical task of the facilitators is to offer daily support to community members. This involves frequent individual email interactions with members to try to address some of the psychological, social and cultural factors that hinder participation.

A founding principle of MyGlobalFund is freedom of speech, but why would you dare criticize Global Fund processes when the money that pays your salary comes from a Global Fund grant? How could you be frank and open about the challenges you are facing in the implementation of your supported program when you hope to make the case for its renewal?

Communicating in writing, in a language which is not a mother tongue for the majority of intended users, is a scary thought for many. This is increased by that fact that they are authorized to express themselves, publish personal thoughts on a more informal media than others, but which can amplify their words through archiving and cross-linking.

One might suspect that, despite this open door to speak one’s mind, few people would have the confidence to express themselves openly and freely. Yet this frank and transparent sharing of experience is at the heart of the knowledge system that MyGlobalFund is seeking to support.

This is where a facilitation team’s daily work comes into play, going well beyond the moderation of discussions. It is about empowering members to communicate, reassuring them individually, reminding them that they are participating in an important cause, and pushing ideas across language barriers by translating them, at least in part. It is also about “getting out of the way”. Trying to manage or control the community would be a fatal mistake. For a community to thrive, it needs to be built on freedom, a space that members feel belongs to them, and not to the institution.

Promotion and daily support played a central role in generating an important volume of content on MyGlobalFund in the first year. This early success can also be attributed to the relative ease of participating in online discussions, like the e-Forum. Forums have been an integral part of the internet since its early days. This form of exchange is widely known and accessible to most internet users. On the other hand, newer tools, such as wikis and blogs, require a deeper involvement and an understanding of effective communication techniques which also need to be supported by training. This may take the shape of short online tutorials, downloadable manuals, video demonstrations, physical presence and presentations at relevant stakeholders’ meetings, or daily assistance through the platform. Who should you target with your blog and with what precise objectives? How do you write for the web? What makes a good blog title and a good story? What is a fitting and meaningful illustration? How do you promote your online communication efforts and measure your success? Training in basic online communication skills is thus a top priority for maximizing the impact of Web 2.0 in a professional setting, one that will help prevent one of the most common mistakes of failed online communities: believing that good communication tools alone can make good communicators[15].

Multiplying entry points and improving usability

When it comes to Internet communications, trying “to reach the unreached” among health professionals in developing countries still largely applies to those living in capital cities. MyGlobalFund targets an audience of implementers (Country Coordinating Mechanisms, Global Fund Principal Recipients and Sub-Recipients, and Technical Partners) with varying connection speeds and unequal access to the web. A survey conducted in October 2008 revealed that although a majority of e-Forum participants were from Sub-Saharan Africa, most respondents said they joined the discussions during working hours on fast internet connections[16], which could indicate that the website is still not the inclusive and wide-reaching platform it aspires to be.

To broaden participation in a global environment, speed of connection to the Internet remains a major issue. Customizable, community-driven sites are powered by heavy scripts and code that can considerably slow down the time it takes to access a page.

One of the key considerations in choosing the technology that runs MyGlobalFund was to allow community members to use the web platform without having to connect to it. All forums come with mailing list subscriptions to let members follow and fully participate in discussions by email. This is particularly important for members with limited access to the Internet and who will prioritize reading and replying to emails when they can get connected.

Forums and blogs are also RSS-enabled, opening up other possibilities to access user-generated content without the heavy web interface that sometimes comes with it[17].

With the spread of mobile technology in Africa and in the developing world, the convergence of the web and mobile phones offers promising opportunities. Another future development of MyGlobalFund will be to enable participation by SMS, short text messages (maximum of 256 characters) which can be received and sent by mobile phones. Members having subscribed to this service would be able to receive alerts on topics, forums or blogs of interest, and send private messages to other subscribed members.

Designing a multilingual collaborative environment for the first time comes with a steep learning curve for any web team[18] and substantial efforts have gone into customizing the technology that runs MyGlobalFund[19]. Solutions on the market offer impressive lists of possible features and functionalities which may prove to be superfluous when targeting large audiences scattered across the developing world.

More importantly, improving the usability of a website that depends entirely on user participation, i.e. customizing its design to make its use self-explanatory and gratifying, is critical, especially in a multilingual setting. Interacting with the site and with other members (posting and replying, commenting, subscribing to mailing lists, contacting members directly, tagging, etc.) should be extremely easy.

The most common method for addressing usability issues is to periodically assemble a focus group (a limited number of people who are representative of one’s audience) in a computer lab and conduct tests to study the way users navigate through the site, using a series of questions and simulations. For a very diverse, global, multilingual audience, like the MyGlobalFund community, this method was considered too complex and expensive. It was therefore replaced by internal testing, the direct observation of users interacting with the site during stakeholder meetings, and the gathering of daily feedback.

In the absence of another reliable method to assess the experience of users with very diverse needs and environments, we implemented regular refinements based on partial feedback. This proved to be time-consuming and slower than if we had been targeting a more homogeneous community (with the same language, age group and internet access) but large investment in this area is required and must remain a high priority.

A partnership in communication

Today’s web is a fully bi-directional platform where every individual has a voice and can easily collaborate in new and powerful ways with other individuals who share common interests. It provides communication opportunities that were unthinkable a few years ago and that can be used as a force for change in health communications.

However, the Global Fund’s experience illustrates that in between the institutional acceptance of using these new technologies and bringing about concrete results, there is a long road to travel.

The membership of MyGlobalFund is growing steadily and members have already used the platform extensively[20]. This project also shows that in order to nurture the right conditions for a community to thrive, there needs to be strong institutional commitment, clear goals and strategic direction, patience and, most importantly, specialized staff with the right sets of skills in community management, communication, training and network building.

It requires focusing on users’ needs and “getting into their shoes”, being willing to play by the rules of a new communications landscape.

International organizations working in the field of public health may find compelling reasons to move, under certain conditions, from vertical to horizontal communications. Web 2.0 tools can serve different purposes and different types of communities, professional or not, public or private, moderated or not.

At a time when people are over-solicited by numerous online communities that compete for their attention, attracting them to yet another community requires offering something they can really make use of, genuine motivation and, of course, the investment of time and the right resources. This can be a long process but in our experience, it is a necessary and very rewarding one.

From the moment the idea was presented to the introduction of a beta version of the website and the official launch, the MyGlobalFund project has gone a long way to try to help create and sustain a community that reaches a size and produces enough quality content to gain a life of its own.

By enabling mass collaboration across borders, languages and cultures, the platform will play a central role in strengthening the Global Fund’s communications with the Global South. In doing so, the Global Fund demonstrates the confidence it has in the experience and professionalism of health experts and partners committed to the global fight against disease, encouraging them to share their thoughts, to communicate on their progress and challenges, to connect with their peers, and perhaps most important of all, to turn conversations into actions that save lives.