Smartphones and Information Management for Rural Health Care Clinics in Africa

1. 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

2. 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

3. 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)

4. Communications Context Mobile GSM Coverage Internet Infrastructure Image composed from coverage maps available on gsmworld.com Map courtesy Eric Osiakwan Africa ISP Association

5. Decentralized Healthcare Tasks • Inventory • Referrals • Statistics Obstacles • Roads • Staffing • Power • Finances

6. Output-based Aid (OBA) Voucher Program • Subsidized voucher for treatment of sexually transmitted infections (STIs) with modified syndromic and lab diagnostics price per voucher brand barcode sticker partner or client

7. Marie Stopes International Uganda (MSI-U) & Microcare Insurance Ltd. Send vouchers Pay service provider Submit claims Record voucher sales data avg 15 days max 45 days avg 30 days max 60 days Clinics (16 at start) Community distributors (44 at start) Provide STI diagnosis and treatment Submit voucher to provider Sell vouchers Pay cash Clients (+350 per month)

8. 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

9. 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

10. 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)

11. 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)

12. 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.

13. 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

14. Framing the questions • Be reflexive - question what you think you know and ask open-ended questions • Observe - find out about their current practices

15. 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?

16. Health Clinic Visits Health Centers (Nakaseke District) OBA Uganda (Mbarara District) MOH UHIN (Kampala) UHIN Deployment (Rakai District)

17. Framing the Context: Nakaseke • Infrastructure • Health Centers • Data Reporting • Mobile Phone Usage

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

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

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

21. HCIV

22. HCIII

23. HCII

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

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

26. 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

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

28. Aggregating Data

29. 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 airtime security network coverage

30. Choosing a smartphone…

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

32. A project champion

33. Report Generation

34. Paper and Digital Data

35. “Sometimes I use it as a torch”

36. Power Issues • Power shortage • Accessibility of relay points • Ownership • Existing Hierarchies • Duplicate Tasking

37. Appropriatable Technology

38. MoH Lessons Learned computers + broadband computer + smartphone smartphone + pdas smartphone or paper

39. Marie Stopes International Uganda (MSI-U) & Microcare Insurance Ltd. Send vouchers Pay service provider Submit claims Record voucher sales data avg 15 days max 45 days avg 30 days max 60 days Clinics (16 at start) Community distributors (44 at start) Provide STI diagnosis and treatment Submit voucher to provider Sell vouchers Pay cash Clients (+350 per month)

40. Structured Facility Survey • Conducted by Richard Lowe as part of a separate evaluation project • Providers vary greatly: • Facility+Infrastructure Differences • Number of Clients • Distance from Mbarara

41. Part of the process • 11/12 Complete claims forms during patient consultation • Timely processing • 7 days: 2/12 • 14-15 days: 7/12 • 30 days: 2/12 • 4/12 have computer training • 12/12 own a mobile phone

42. 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

43. Paper vs Digital • Paper is a powerless backup • Authentication using physical artifacts • Flexibility signatures clinic stamp client fingerprint voucher barcode

44. 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

45. 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

46. 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