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_at_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
Submit claims
Pay service provider
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
Lessons Learned
MoH
computers broadband
computer smartphone
smartphone pdas
smartphone
or paper
39
Marie Stopes International Uganda (MSI-U)
Microcare Insurance Ltd.
Send vouchers
Submit claims
Pay service provider
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
• FacilityInfrastructure 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 --gt Infrequent Submission
• 6/12 providers claim that delays in payment
  interferes with ability to serve patients
• 4/12 dont 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