Smartphones and Information Management for Rural Health Care Clinics in

Africa

Melissa Ho (mho@ischool.berkeley.edu)

PhD Student, School of Information

“Global Development in Action” Student Symposium

Thursday, October 4, 2007

Blum Center for Developing Economies, UC Berkeley

Moving right along…

A quick overview of the context Communications Infrastructure Healthcare Information Practices What is a smartphone?

Research Framework Findings on the Ground

Framing the Context Learning from Experience Proposing Solutions

CIA World Factbook

Population: 30,262,610 Infant Mortality Rate:

total: 67.22 deaths/1,000 live births

HIV/AIDS prevalence: 4.1%

Landlines: 108,100 (2006)

Mobiles: 2.009 million (2006)

Communications Context

Image composed from coverage mapsavailable on gsmworld.com

InternetInfrastructure

Mobile GSM Coverage

Map courtesy Eric Osiakwan Africa ISP Association

NakasekeDistrict Hospital

Semuto HCIV

HCIII HCIII

HCII HCII

Ngoma HCIV

HCIII

HCII

HCIII

HCII

Decentralized Healthcare

Tasks Inventory Referrals Statistics

Obstacles Roads Staffing Power Finances

Output-based Aid (OBA) Voucher Program Subsidized voucher for treatment of sexually

transmitted infections (STIs) with modified syndromic and lab diagnostics

brand price per voucher

barcode sticker partner

or client

Marie Stopes International Uganda (MSI-U) & Microcare Insurance Ltd.

Community distributors(44 at start)

Clients(+350 per month)

Clinics(16 at start)

Submit claims

Pay service provider

Sell vouchers

Submit voucher to provider

Send vouchers

Record voucher

sales data

Provide STI diagnosis and

treatment Paycash

avg 30 days

max 60 days

avg 15 days

max 45 days

Smart Phones

Electronic hand-held device Functions as a mobile phone Provides internet access Has built-in keyboard Additional capabilities:

E-mail Word processing and

spreadsheets GPS

Custom programs can be installed

Why Phones in Rural Areas ?

Already widely prevalent in developing regions Usage familiar to rural users Powerful enough to be used for computing resources,

rather than just communication – so possible PC replacement for vertical tasks

Suitable for rural areas: low power, robust, cheaper, lower operating cost, use existing networks

Integrated features: camera, GPS, audio Appropriate for use across multiple households

Rural Data Collection Problems

Data frequently missing or incorrect or contradictory. E.g. sex is male but pregnant is yes on health form – very hard to validate after the fact

Forms are very long and frequently incompletely filled – questions are not prioritized if partially filled

Data collected not rich enough – no audio, pictures, GPS without specialized hardware (and also not integrated)

What Can Smartphones Offer ? (1)

Immediate Validation Correct data upon entry, and also crosscheck with other fields if

dependencies exist

Dynamic Forms Reduce burden on health worker by asking only relevant

question based on previous answers, thus reducing chances of errors

Also makes partially filled forms more useful

Richer Data collection Photos, audio input, GPS (entire medical record possible)

What Can Smartphones Offer ? (2)

Auditability Audio samples can be used to double-check responses

Transparency Generating reports of and viewing system-wide statistics and data

Operation in disconnected areas Use only for computation, communication not necessary for collecting

data on the field

Synchronization of data When connectivity is available, upload to central server over the

cellphone network either through multiple SMSes, or data packets over GPRS, eVDO, etc.

Expected Results

Increased data accuracy Improved data timeliness Reduction of burden on healthworkers Reduction of the number of times surveyors

have to be re-sent back into the field to redo surveys because of errors

Better organization of data

Framing the questions

Be reflexive - question what you think you know and ask open-ended questions

Observe - find out about their current practices

Identifying Pain Points

What are the current processes? What do health workers do on a day to day basis? What are the data collection and information management practices?

Who are the key players? Is there a local “champion” and local collaborators? Who is using health information?

What infrastructure is available? Do the health workers have fixed line or mobile phones? How do they communicate with their superiors and subordinates? How is information relayed using current infrastructure? What communications infrastructure is available but not being leveraged?

Metrics What metrics are important to the community? How do they currently evaluate their own successes?

MOHUHIN

(Kampala)

UHIN Deployment(Rakai District)

OBA Uganda(Mbarara District)

Health Centers(Nakaseke District)

Health Clinic Visits

Framing the Context: Nakaseke

Infrastructure

Health Centers

Data Reporting

Mobile Phone Usage

Poor road infrastructure makes it difficult (and expensive) to travel between the health clinics and the hospital

Hospitals and upper-level health centers often have co-located water pumps for the community

Public health campaigns are carried out through radio and posters like these

HCIV

HCIII

HCII

The Ministry of Health mandates monthly and weekly reporting of outpatient statistics

This district hospital keeps all of the HMIS forms from each of the health centers in its district here

Creating the reports…

Data is collated from hand-written patient ledgers (sometimes exercise books)

Forms are completed in triplicate

Submitted within 3 days of the end of the month

Hand delivered to the District hospital

One particular health center was very conscientious about recording data and producing graphs to visualize trends

Aggregating Data

Mobile phone use in HCs

Every health center has at least one

personal mobile phone

Innovative charging solutions

Current Uses

Emergency reporting

Submitting weekly HMIS forms

Checking salary and drug order status

Requesting transportation

Clinical consultations

securityairtime

network coverage

Choosing a smartphone…

Learning from Others: Healthnet

Reference: Uganda Health Information Network IDRC Report, 2004 (http://www.healthnet.org/idrcreport.html)

A project champion

Report Generation

Paper and Digital Data

“Sometimes I use it as a torch”

Power Issues

Power shortage

Accessibility of relay points

Ownership

Existing Hierarchies

Duplicate Tasking

Appropriatable Technology

NakasekeDistrict Hospital

Semuto HCIV

HCIII HCIII

HCII HCII

Ngoma HCIV

HCIII

HCII

HCIII

HCII

smartphone

smartphone + pdas

MoH

computers + broadband

computer + smartphone

or paper

Lessons Learned

Marie Stopes International Uganda (MSI-U) & Microcare Insurance Ltd.

Community distributors(44 at start)

Clients(+350 per month)

Clinics(16 at start)

Submit claims

Pay service provider

Sell vouchers

Submit voucher to provider

Send vouchers

Record voucher

sales data

Provide STI diagnosis and

treatment Paycash

avg 30 days

max 60 days

avg 15 days

max 45 days

Structured Facility Survey

Conducted by Richard Lowe as part of a separate evaluation project

Providers vary greatly:Facility+Infrastructure DifferencesNumber of ClientsDistance from Mbarara

Part of the process

11/12 Complete claims forms during patient consultation

Timely processing7 days: 2/1214-15 days: 7/1230 days: 2/12

4/12 have computer training

12/12 own a mobile phone

Struggling to Participate

Providers travel up to 3.5 hours to submit claim forms

Fewer clients --> Infrequent Submission

6/12 providers claim that delays in payment interferes with ability to serve patients

4/12 don’t know how many claims have been rejected. 3 have not gotten feedback

Paper vs Digital

Paper is a powerless backup

Authentication using physical artifacts

Flexibility

client

fingerprint

voucherbarcode

clinicstamp

signatures

Open Questions

Pushing verification to the client Eliminate simple errors Biometrics (e.g. fingerprint, photo) ?

Paper and Digital Is there a low cost printing solution? Can we make the digital process advantageous for all parties?

Training and Usability Power Privacy and Information Security Sustainability, Scalability

Execution

Co-design and Co-deploy Local collaboration is key to the sustainability and appropriate

design of the system Collaborating with Mbarara University to integrate solar power into

health centers Development

Leverage computer scientists at Mbarara and Makarere Develop SmartForms in collaboration with people who will be using

them: records officers, nursing assistants, in-charges Training

Develop training plan and information practices with local stakeholders

Specialized training for key Handoff of Maintenance integrated early in the project

Acknowledgements

Thanks to all of the Blum East Africa Fellows, especially Katrina, Mallory, Simon, and Admas for letting me observe and participate in their project

Thanks to Professors Kristi Raube, Sandra Dratler, and Eric Brewer for faciliating this research

Thanks to Ben Bellows, Richard Lowe, Francis Somerwell, and all others at MSIU and Microcare

Thanks to the Blum Center for Developing Regions for inviting me to speak and financing this research