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Claim Mobile

Claim Mobile at CHI2012!

I’m happy to share that I’m presenting two publications at CHI this year.  The first one is a followup to my first paper on Claim Mobile, and discusses the invisible constraints that ultimately led to my decision not to deploy the system for the Reproductive Health Voucher Program (RHVP).  The second is a case study describing the Bulk SMS system that I helped to commission and design for RHVP – primarily used by the NGO to send out payment notifications to all of the health facilities.

Claim Mobile: When to Fail a Technology. M. Densmore. In Proc. of ACM SIGCHI Conf. on Human Factors in Computing Systems (CHI 2012), May 2012. Forthcoming 

Experiences with Bulk SMS for Health Financing in Uganda. M. Densmore. In Proc. of ACM SIGCHI Conf. Extended Abstracts on Human Factors in Computing Systems (CHI EA 2012), May 2012. Forthcoming

Shortly after CHI, the book chapter co-written by Susan Dray and many others will finally be available – Look for it!

Human Computer Interaction for Development:  Changing HCI to Change the World.   S. Dray, A. Light, A. Dearden, V.Evers, M. Densmore, D. Ramachandran, M. Kam, G. Marsden, N. Sambasivan, T. Smyth, T., D. van Gruenen, and N. Winters. In J. Jacko, Ed., The Human-Computer Interaction Handbook: Fundamentals, Evolving Technologies, and Emerging Applications, Third Edition (Human Factors and Ergonomics) CRC Press, 2012, pp. 1369 – 1394.

Orange You Glad You Have 3G?

3G is a game changer.

As I mentioned in my last post, new technologies are being introduced primarily by the mobile service providers.  And for as much as I’m developing bits and pieces of software, my research is to introduce these technologies to the healthcare service providers (HSPs), to educate them on their use, and to study how they are assimilated.

Brief aside: For you students out there, what makes this a vaguely experimental context is that I’ve manipulated the context by forcing the introduction of computers, Internet, and Internet-enabled mobile phones, so I can ask very specific questions.  It’s only vaguely experimental because there’s all sorts of exogenous variables that I can’t control and, well I only have 8 subjects that are ultimately wildly different from one another.   All the statistical data I presented in my last post was from a survey of 59 health facilities, so that’s slightly different… but also to be discussed.

Okay, now this is long overdue, since MTN changed their GPRS settings at least 6 months ago.  But this week and next I’m setting up my 8 facilities with mobile Internet, so yesterday I went to Warid, MTN, Orange, and Zain and purchased Internet plans from each of them.  (UTL has CDMA and DSL broadband services, so they don’t offer GPRS services by monthly subscription, although they do have 3G equipment installed on their masts in Mbarara. We don’t know what their deal is.) Here’s a run down of all the prices:

The prices listed are in Uganda Shillings (conversion varies from day to day, I think it is actually about 1950 UGX to USD, but I generally use 2000 as my conversion rate for this blog, for round numbers, and so I don’t have to get out a calculator.)  For Orange and MTN, they offer discounted rates if you subscribe for multiple months. You can view Orange’s price list and coverage area online, and MTN’s price list as well.  Warid calls their plan Smartlink.  A primary thing to note is that not only is Orange half the price of the others, but Orange has 3G coverage in many of the major towns throughout Uganda, including Mbarara.  Practically speaking, this means I can watch live streaming video on the BBC News website using my Orange modem, and use skype again. Yikes.  My one modem is faster than the entire Mbarara University VSAT connection.  At the same time… I took the modem to Kaberebere yesterday, about half an hour away to a health facility, where only EDGE coverage was available, and I was only getting 4Kbps instead of 100Kbps, and when I took it to Kanoni, it didn’t work at all, so it really depends on where you are.

I spent yesterday morning purchasing mostly just the SIM cards from each of the providers – which I get away with because I’ve previously purchased modems from them and they all know me.  Usually you’ll have to argue with them if you try to purchase a monthly subscription without a modem, and prove that you have a phone that’s capable of handling it.  They just don’t want to deal with third party modems.  Don’t tell them that you have one if you do.

For each one, if you know what you are doing the APN is listed above, and the username and password is blank. IP address and DNS settings are automatic, and there are no proxy settings.

With Warid, there’s a trick – there’s a current promotion, in which for all the airtime you load, you get bonus airtime, which can be used for calling, but not for things like Pakalast or Internet.  So I loaded my personal phone with the airtime for the Internet and then transferred the airtime to the Internet SIM.

You don’t have to go to a Warid office to activate Internet on your Warid line.  Just send an SMS with the words data 85 to 158. Warid will deduct 85,000 from your account, and you will get 30 days of Internet.  Make sure you have 85,000 UGX already loaded on your phone.   By my experience I usually just go to the customer care office because no one but them actually sells that much Warid airtime… You can also send the words data 5 to 158, and you will get one day of Internet instead for 5,000 UGX.  I was told also that you can check your SIM card: if you have a 32k SIM card rather than a 64k SIM card, you may have some difficulties with Internet, and you should get your card replaced.  I have, however, never had a problem with using a 32k SIM card on a pay-per-kb basis.

For MTN, if you already have a line, and you don’t have Internet, you can call customer care on 123 and tell them you want Internet to be enabled on your phone.  If you already have 90,000UGX on your phone, then you can ask them to deduct that from your balance and then they can subscribe you.  Or you can just enable Internet and start using it at the pay-per-kb rate.

For Zain, once you first connect to the access point, you will need to activate a plan before using the Internet.  If you go to the store, then they will do this for you.  Now, first, I will mention that yesterday and today, Zain has been very very flaky – the coverage has been okay (totally down in Ruharo) but the AP has been down more often than up.   However, once you are able to connect you need to use a web browser to connect to http://www.zain.com.  You will then be redirected to a page that will invite you to choose between three Zain plans, Zain Access, Zain 1GB and Zain True Unlimited.  Zain Access is the pay-per-kb plan, Zain 1GB is the monthly plan for 90,000UGX per month, and True Unlimited is another monthly plan with no bandwidth cap, at a price I don’t remember.  Click on the link corresponding to the plan you want and it will display the name of the plan, its validity, and the price.  Then click on the subscribe link.  From there it should take you back to the Zain page and you should be ready to go and use any mobile web application on your phone.  Note – if you select Zain Access, you won’t be able to switch to Zain 1GB for at least one month on that same SIM card without a LOT of hassle, so make sure you know which plan you want to be on.  Or just get two SIM cards.

Orange offers 1GB, 3GB, and 10GB plans, both with and without their modems.  If you choose not to purchase their modem (150,000 UGX) then you have to subscribe for a minimum of 3 months. I tried to purchase one instance of this plan yesterday and was told that they were sold out of modem-less Internet SIMs and would have to return the following week, so clearly modem sales are a priority.  And iPhone sales. At 3G speeds, 1GB gets used up really really quickly.  3GB is probably reasonable 10GB is pretty expensive…

If you are using your mobile phone, most networks will try to configure your phone over the air (OTA).  I haven’t had a lot of success with the OTA configurations on my Nokia, and none with the Palm phones. But whatever.

If you purchase a modem from one of these providers, you’ll find that the modems from MTN, Warid, and probably Zain (they have a new modem now that I haven’t tried) all include OSX-compatable software.  I don’t use it.  The Orange modem doesn’t come with software, but is made by the same manufacturer, a Taiwanese company called Huawei.  Basically, I go into my Network Preferences, select the “HUAWEI Mobile” device, and add a new configuration.  From there I click the “Advanced” Button, and the Modem window displays.  For Vendor, select “Generic”, for Model, select “GPRS (GSM/3G)”, and enter the APN as above.  All other settings under advanced can be left as default.  If you have any proxy settings, you might want to uncheck them.  Click Ok to save your advanced settings, and then enter *99# as the telephone number. Click Apply.  Then Click Connect.

On a Mac you can also share your Internet connection with other WiFi-enabled people in the room.  Once you are connected, click “Show All”, then double-click on “Sharing”.  If you click on the words “Internet Sharing” you will see options for “Share your connection from:” and “To computers using.” Select the appropriate options (i.e.  Huawei Mobile and AirPort respectively) and click on the checkbox next to Internet sharing.  If you are successful it should  1) turn on your airport if it is not already on 2) ask you to start Internet sharing  3) turn your little wifi icon into an up arrow.

Of course, now having one of each network (except UTL) and being able to test them side by side in multiple locations I’m learning their differences.  I’ve extolled Warid and Zain before as having better performance, probably because their network isn’t glutted by lots and lots of users.  However – now the situation is different.  Warid has a lot more users, and it seems that I can barely get the modem to connect.  Zain is just having technical difficulties right now – I’m not sure if that is temporal or endemic.  After my previous post, I discovered that both Warid and Zain are much better in Kampala.  But from my perspective – it doesn’t matter – it’s much more important to ICTD to know how all of these networks are performing in the villages and towns outside of Kampala, for rural health centers where our potential users are, where the so-called bottom billion are receiving health care (or not receiving health care, as the case may be).

I’ve been putting up coverage maps for the past year, claiming that wherever there is mobile coverage there is GPRS coverage.  This is only partially true.  I just went to Kanoni on Monday and found that I couldn’t get any of my phones to connect to the Internet successfully – there was extremely weak phone signal, and no GPRS coverage.  I even got the Orange software to connect.  To no avail. (it connected on windows, but not on OSX, or on my phones) We suspect, it might work on Zain, but I didn’t happen to have a Zain card on me… and I’m worried, given the quality of the Zain network here right now.

So there’s theory and reality.  Orange makes a claim “All areas covered by the Orange network have EDGE available with speeds of up to 236kbps.” And yet in Kanoni we had 2-3 bars of reception, with no Internet at all.  I travelled to Ibanda with the doctor finally, and we uploaded his attachment at a whopping 1-2kbps.  Yes, we were connected using EDGE, but it was a slow and painful (dare I say dull?) EDGE.

And yet it is the best we have.  The best I’ve seen Warid connect with out here is GPRS. MTN connects in general using EDGE, but always more slowly than Orange, unless we’re out of an Orange coverage area (e.g. in Ruharo). MTN’s fallback in rural areas is GPRS, Orange’s fallback in rural areas is EDGE.  Much of Isingiro, a district bordering Tanzania, the location of the Uganda UNDP Millenium Village Project, has very little Orange/Warid/MTN coverage, and is only accessible by Zain. In those locations, Zain is the only recourse – and 3G is available (or so it is rumored).

In my office, Orange is faster (and cheaper) than our VSAT connection, and doesn’t go out when there are power cuts.   We used it to download all of the Windows updates for the six deployed laptops in my research study, with little effect on the connection performance. Useful. And I can skype again, not that I have the time these days… =)

I am deploying these modems according to which network works the best for the various providers in their facilities.  Each of them will get a subscription for one month, after which they are free to continue subscribing on their own, or to return the modem to me.  After the second month, they will have to arrange to purchase the modem from me or from the appropriate mobile phone company.  They also are equipped with Internet enabled mobile phones, and are keeping logs of their usage and spending.  Hopefully by the end of two months they can make an informed decision as to whether they would prefer to use Internet on their phones (cheaper but limited) on subscribe to Internet on laptops (expensive but more flexible).

I know it is a little weird to be working in development but to still be telling people in Africa to spend money. But I’m also perfectly fine with any decision, whether they choose to forego the phones and laptops altogether, or to spend lots and lots of money for everything.  I just want to learn their preferences, and why they make these choices, and how what they learn changes their choices and how they communicate.

Entrepreneurship in Uganda

I’ve always thought that Africa was full of entrepreneurs – thousands of people eking out a living in container stores and markets selling goods a minimal profit, so they can support their families, send their kids to school, and, in general, survive.

Now, there’s clearly a difference between the startups of Silicon Valley that get venture capital and make millions, and the small business owners that run grocery stores or laundromats, and street hawkers that sell chewing gum from baskets on top of their heads. Profit margins are one.  But everyone has to start somewhere, and not everyone has the same connections; certainly environment and geography plays a large role in the probable capacity of an individual to aspire.

So what does it take to start a formal business in Uganda? To be a small business owner?  I’ve been encouraging some of my students along these lines, and thinking about the “Coded In Country” concept.  One thing that plays a large role in the ability to build local capacity is the country’s business environment; how hard is it to start and run a company in Uganda?

After a bit of word-of-mouth consulting, and talking to some small business owners here, I turned to google, and found the Doing Business Project, which provides indicators on 10 topics in 183 economies.  While the data itself is also very useful, from a very practical standpoint the fact that they’ve documented all of the (18) steps for starting a business in Uganda, and put them on the web is totally amazing to me.  This is not formal e-governance, since the government isn’t the one putting this information on the web, and in theory, the gov’t could change the policy, making this document out of date. However, this does make things easier for people… as long as they have Internet access and pick the right search terms (e.g. “starting a company in Uganda“).

Now, what does this information mean for my students?  Mostly it means that they need to hire a lawyer to incorporate as a partnership.  We’ve consulted with a friend of a friend of theirs, and it will cost about 365,000 UGX (180 USD) in licensing and lawyer’s fees to go through the entire process. Their hope is to start a company that uses information technology to support healthcare in Uganda, through the development of software and the support of IT systems. They are helping me by providing ongoing computer and mobile phone maintenance to the healthcare providers I’m working with, even after I go back to the States, and working on supporting the software we’re developing.

Now they just have to come up with a name for the company…

Bringing ICTs and Solar to Rural Uganda

Dembbe Clinic WECARE Solar and Netbook Deployment

Dembbe Clinic WECARE Solar and Netbook Deployment

Kathe Medical Care Netbook Deployment

Kathe Medical Care Netbook Deployment

Barefoot Power PowaPak and Palm Treo Deployment

Barefoot Power PowaPak and Palm Treo Deployment


While my study hasn’t quite officially started yet (most of my equipment is en route via Cairo right now) I’ve started deploying some computers and mobile phones in a few health facilities, just to give them some time to familiarize themselves with the equipment, and to give myself and idea of what I’m going to run into with the other clinics when they get the equipment too.

Here’s how my research works: There’s a lot of complicated stuff about claims and claim processing. However, what I actually do is a lot of qualitative research on how people do their work, perceive information technology, and manage information. Then I introduce new technologies, and then ask them what they think of them, and see what they do with them. Sometimes I’ve done weird things with these technologies (like umm.. written them or installed specific software), and I definitely have a specific approach – I interfere with my subjects a lot in terms of computer training, and in the case of my partnering agency, being an IT consultant in this office for 15 months.

My baseline studies and are showing that my target user base 1) has a high interest in using information technology for patient information management but 2) very little training (for the most part). So if I were to introduce a new system, let’s say a laptop/netbook, 1) they would be very interested in learning how to use it, even paying for it but 2) they would have little to no background knowledge on where to start.

This has deep implications for user interface design. For many people, they choose a “kiosk” approach, making computers that have only one application (also known as the “appliance”). However, this has implications on sustainability. For private health facility owners who need additional skills, or for programs that cannot be expected to finance the equipment externally – paying for purpose-built machinery when the computers are capable of general purpose applications is impractical.

In this case – Claim Mobile is probably not a sufficiently valuable application to motivate purchase of laptops or phones. However – the phones, bundled with a camera, medical calculators, bible readers, internet browsing capabilities, etc, and the netbooks, with Microsoft Office, and Hesperian ebooks, and other medical resources, Barack Obama’s speeches, and the ability to access the Internet are of great value to the health facilities, and to the program management of the Uganda OBA project, even without the claims processing component.  However – we hope to find out in this study how this value will actually play out against real purchasing decisions: laptops vs phones, Internet subscriptions vs pay per kb Internet use.  In addition, we will observe over time how the health facilities and the Uganda OBA project will make use of their ownership of these devices, and how the new uses play into relationships, communications, and the management of the OBA program in general.

Some caveats about the deployments so far.  Out of the first three deployments, two facilities did not have power.  In one location, we donated a solar suitcase to Dembbe Clinic through WE CARE, an organization I’m involved with that seeks to provide improved electricity and communications for maternal health care.  The two 20W panels provide sufficient power to charge the netbook, phone and lights for the facility.

In the second location, we are experimenting with the Barefoot Power Powapak, which provides solar led lighting sufficient for rooms (not quite surgery), and a cigarette adapter to charge phones. However I went back on Monday to check on the solar deployment, and discovered that the battery was completely discharged – probably because the solar panel was failing to charge the battery.  I’ll introduce some solar logs to have them track usage more closely in January. The phone is being charged every few days from the clinician’s other place of work, which has access to electricity.

The third location, Kathe Medical Care, has very reliable access to electricity, because they are on the power line connecting to Rwanda. However, what interests me about this particular clinic is their innovative uses of ICTs prior to the study.

IMG_1312

Kathe Medical Care analyzes output indicators by local sub-districts

During my baseline surveys, I was introduced to Kathe Medical Care’s many colorful computer generated graphs and charts, all produced from the government-mandated monthly summary data.

There were charts showing trends of increasing numbers of antenatal visits over the past year, since the beginning of the OBA program, charts, comparing non-OBA deliveries to OBA deliveries, and charts showing from which  sub-counties patients were coming.

I learned that the clinician did all of these from an Internet cafe, taking his monthly reports to Mbarara each month, entering them into Excel, to produce the charts.

Based on these charts, I assessed this clinic, and had high hopes that I would be able to learn from him how other clinics could use their data to benefit from computers.

I also assumed that he had a usb flash drive.

But to my surprise – one of his statements upon entrance into this study was that he had been giving people these charts for a while and hoped that at some point  someone would think to give him a flash drive. You see it turned out that each time he produced one of these charts, he was entering in another year’s worth of data, all over again – he had nothing on which to save the Excel spreadsheet that he was using to create this chart. I think none of us ever imagined he could achieve so much without a flash drive in the first place!

This sort of begs a question: clearly he has enough income to purchase a flash drive, if he’s willing to purchase a netbook, and even a printer… What stopped him? (This is another blog entry entirely, maybe a paper or two).  There’s a lot to be said at this moment about 1) trust in electronics purchased in Uganda and 2) the perturbation that I am as a ethnographic researcher in this environment.  But I won’t say it now.

In the meantime… given what he was doing without a flash drive, and with the nearest Internet cafe an hour away at $1.50/hour,  let’s just imagine what he’ll do with his own netbook and Internet access.  Or perhaps not imagine… we can wait and see.

They Fixed the Kindle!

Omigoodness. I managed to get my hands on a Kindle 2 this past weekend and aside from the fact that the Whispernet (Amazon’s renaming of Sprint’s EVDO Internet service) is totally inaccessible for me, and it would be an absolute pain for me to actually put any books on the device, I really really really want the new Kindle. :)


Kindle 2 ($360) Kindle (discont’d) Sony Reader PRS-505  ($299)

My major complaints about the original Kindle were that it was flimsy, thick, clunky, and the buttons were not well designed. The plastic it was designed from made its weight distribution funny – so it actually even aggravated my tendonitis. I liked the WhisperNet feature, and the keyboard – but the slowness of the screen made annotating books a pain at best, and referencing the annotations wasn’t really useful enough to merit the design flaws. Amazon’s closed ebook format isn’t great either – most of stuff I want to read just happens not to be available in Kindle format (i.e. academic papers, textbooks, papers that I’m reviewing/editing), so I ended up with the Sony Reader which supports viewing of native PDFs as images, with additional support for portrait or landscape viewing (I wish there was a button), and a zoom button for magnifying the text if you have OCR’d text accompanying the image. Since I didn’t want to take a suitcase full of books with me to Uganda, I sliced the bindings off of them, scanned them to pdf and OCR’d them, and I’m reading them on my reader instead. Much better carrying a slim e-book reader on the plane than the 2-inch thick copy of James Scott’s Seeing Like a State.

The Kindle 2 is even slimmer than the Sony Reader, also comes with a leather case, and has the advantage of incorporating wireless and a keyboards for just $60 more. Kindle has access to a larger selection of copyrighted e-books, “Kindle Editions” at much better prices, with a much cleaner interface. Sony’s software, frankly, is flaky, slow, and crashes a lot. But at least I can put my PDFs on it directly. I think for the Kindle I still would have to email my PDFs to amazon and pay them 10-15 cents to upload them to the Kindle in some weird, potentially mangled, format. I might be able to put up with that from Berkeley, but depending on email access for giant PDFs out here is totally impossible. And I like my WYSIWYG PDFs. In that sort of vein – Sony’s ebook philosophies are actually more “free thinking” than Amazon’s (for all those copyleft people out there) and the Sony Reader supports the open eBook format (ePub), and as Wired notes, actually provides access to more public domain books than Amazon offers on the Kindle through a recent deal with Google Books.

What I really want is for Amazon to build a Kindle that supports GSM, so I can stick a Ugandan SIM card in it and download Kindle books over the local network? Please? Or I guess I can wait until i get back next year…

I have this vague theory that the Kindle devices might make decent computing platforms for rural areas.  Imagine – data connectivity, low-powered devices that don’t need to be charged more than once every two weeks or so, built-in keyboards, screens that are visible in sunlight, a large screen, and a price point comparable to smartphones, or less?  What the heck am I doing working with smartphones with tiny screens, batteries that die in a day, and keyboards that are too small for healthworkers to read?  Oh yeah… waiting for the ebooks to take off, the platform to stabilize and open up, and um.. trying to finish up my dissertation before starting another project. But if amazon is willing to throw some summer interns at me this year, and a few Kindles, I think I could manage to host them here in Uganda.  Umm.  We just need to find an EVDO network or get Sprint to subsidize the roaming charges? =)  Anyone know someone at Amazon?

There’s also a Sony Reader PRS-700, which I haven’t seen, retailing for $399. It includes an LED light (which I think is great, since I can’t get my booklights to attach, and I think it is lame to have to wear my headlamp to bed, or to have to lift the mosquito net to turn off the lamp on my nightstand), and a touchscreen. I can’t imagine how the touchscreen actually works – I think it’s something I’ll have to see to really understand/evaluate.  But ultimately I think Sony will have to move towards integrating wireless into their readers…

First HealthyBaby Birth

The mother receives the baby from the nurses at the clinic.

The mother receives the baby from the nurses at the clinic.

As I have been pre-occupied with writing lectures for my class, and setting up my research, my collaborating partners at Marie Stopes International Uganda have been busy launching a new phase of the output-based aid voucher program, financing in-hospital delivery of babies, in addition to the in-clinic treatment of sexually-transmitted infections (STIs). The new program, called HealthyBaby is eligible to mothers who qualify under a specific poverty baseline and covers four antenatal visits, the delivery, and a postnatal visit. Last week they just started distributing vouchers, and this past weekend was the delivery of the first baby whose birth was covered by the program.

Like the HealthyLife program, the mother purchases a voucher for 3000 USh (approximately 1.50 USD, the HealthyLife program charges 3000USh for a pair of vouchers treating both sexual partners). The voucher then can be broken into several sticker stubs, one of which is submitted with a claim form on each visit.

The first mother puts her thumb print on the HealthyBaby claim form

The first mother puts her thumb print on the HealthyBaby claim form

The hospital then submits the claim form with the voucher to the funding agency (my collaborating organization), who then pays the hospital for the cost of the visit – labs, any prescriptions given, the consultation fee, etc. You can see in the picture to the right the nurse filling out the paper form and the mother putting her thumbprint on it. Filling out the forms can be tedious and error prone – this particular clinic had almost 18% of their STI claims rejected for errors last October. In the same month another clinics had 38.6% of their claims rejected. I am trying to work on digital systems that can help improve communications between the clinics and the funding agency, and also decrease the cost and burden of claims administration.

The Claim Mobile project actually focuses on the HealthyLife program – the STI treatment program, rather than the HealthyBaby program, but I hope to demonstrate the sustainability and replicability of the system that I’m developing by training the engineers here to retool my system for HealthyBaby – so by the time I leave, I am hoping it will be in place for both programs.

By coincidence, this first birth occurred in one of the two clinics where I’m running the pre-pilot of the Claim Mobile system.

Ubuntu-ifying the eeePCs (Netbook Mania Part II)

(Warning: This one is for the techies)

So I mentioned before that I purchased a bunch of eeePCs to test out in the health clinics and to use in the management agencies as asyncronous web servers and health information management devices.

I suppose to some extent that in retrospect these clinics will have wanted Windows on these laptops so I’ll eventually have to port all of the software to windows, but for now my systems are running on Ubuntu.  It’s just easier that way. 

Installing Ubuntu was remarkably easy. There’s instructions online here, as well as lots of hints and fixes.  This is sort of my simplified version for the particular eeePCs I was working with.

Ingredients:
    1 latest distribution of Ubuntu (currently 8.10)
    1 external usb cd or dvd-rom drive (e.g. the LG-GSA-E50L 8x USB DVD-RW)
    1 eeePC (i.e. the eeePC 1000HA, 10in, 160GB, 1GB RAM, 6-cell Battery)
    1 wired Internet connection (and presumably an ethernet cable)
    Note: In theory you can also install from a USB Stick

Instructions:
    1. When turning on the eeePC, press f2
    2. Verify that a) wifi is turned on (this is for later) and b) the usb device is listed first in the boot order
    3. If the dvd device is not connected, with cd burned with the latest copy of ubuntu on it inside already, do that now, and then continue booting
    4. Install and continue, following normal instructions
    5. After install completes, update all packages via a wired Internet connection
    6. From fixes page, you will note that wireless does not yet work. You’ll want to follow the instructions there, but do not do the modprobe ath5k. However, you do need to install the backport modules:

  sudo apt-get update
  sudo apt-get install linux-backports-modules-intrepid-generic

Wireless should work after this. I used Ubuntu Ibex 8.10

I neglected to put in all my arguments for netbooks vs the mac minis we used in the Ghana consultation network, vs locally purchased desktops, vs actual servers. Basically it boils down to the fact that the netbooks have built in batteries, so we don’t have to purchase UPSes to use as backup power for then the power goes out. And we don’t have to track down a separate monitor, keyboard, and mouse every time we want to do something, which was frankly a pain, when we were working with the minis in Ghana, and couldn’t access them via the network. Laptops are designed to be disconnected from power on a regular basis, and have built in peripherals. Convenient. And actually cheaper than the minis, if a little underpowered, comparatively.

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Netbook Mania

So one of the outcomes of my study last August is that admittedly.. people don’t want mobile phones for their health records, they want laptops. And these new netbooks – well they cost the same as these smartphones. But last August, the eeepcs had a battery life of 1.5 hours and only about 4MB of storage. So when they died in the middle of the comparative studies, all of the people I talked to changed their minds and said that battery life was a non-starter; they had to have something that would last. I did a little shopping though – and for just about $50 more, you can get a standard hard drive (instead of solid state), and a 6 cell battery, and end up with a 10in eeePC that lasts for 7 hours and has 160GB of hard drive space.

Even without the new configuration, people are raving about these netbooks. They won’t let me take them back to the states, and people keep buying them off me – so I have to replace them when I get back home, using the cash people give me. More stuff to carry when I come back – it’s a wonder I always make it through customs with my 6-8 laptops..

The reaction to my laptops this time is that everyone wants to buy these off of me “when your project ends” – to which I always say that when my project ends, the laptops will still be in use because the project will continue without me – unless they are already certain of my failure (I hope not!).

The proposal for now is twofold: two of the laptops will be used as asynchronous web servers, akin to the design used in the Ghana Consultation Network, allowing the Program Management Office in Mbarara and the Management Agency Head Office in Kampala to access claims information even when their Internet connection is down – basically, since the processor will certainly be slow, it will be a caching agent. (I might try Google Gears as well and see if that works better, but this is something that I can intelligently back up and that they can own locally.) The rest of the laptops will be allocated to two of the private health clinics for use in administering their claims forms. However – a primary distinction from the mobile phone solution is that they don’t include communications technology. I will explore a couple of options – including both a sneakernet style solution of sending the forms by SD card, or the more expensive solution of attaching a falcom modem to the laptop, which essentially doubles the cost of the laptop. A few other clinics will be assigned mobile phones, and the remaining clinics will be controls – I will visit them, continue to run surveys, and observe claims administration, and monitor their transcations, but I won’t deploy services there for at least the first 9 months, although I may encourage my partners to independent conduct their own deployment (i.e. with my supervision but not done by me) towards the end of my study.

This study involves simultaneously understanding both the technical feasibility of these solutions and the financial feasibility of these solutions – it will take time to make the service providers understand the ramifications of the various solutions – and the resultant costs and benefits to them. What are the tradeoffs they will make in the end? I think different providers will choose different means in the end.. and it is entirely possible that they might choose to purchase a laptop but not use it for online claims submission, purely for its other utilities. Or because the service provider is of higher means and higher claim volume, they might choose to do online claims submission and pay the service fees because timely payment is so extremely critical for them. I’m curious to see what happens, and I can’t wait to see how it all unfolds.

Back in the Field

I’m on my way back out to Uganda, this time to run a pilot study of the software, working out some of the details of the design (co-design?) with the people in the management agency and the clinics, and doing a comparative study between a bunch of possible device platforms: Palm 680, Palm Centro, Blackberry Curve, Nokia n810 Internet Tablets, and the Asus EeePC with a GPRS modem.

But mostly, I’m making plans for my main dissertation research: one year of fieldwork starting in January of next year, in which the first 6 months will be allocated towards design, deployment, and training around the claims management system. For the last six months, I’m hoping to have handed off all training and implementation to the project partners – I’ll be geographically available, but mostly I’m sticking around to observe what happens when I let the ICTD project sit around and mature – how will my project partners appropriate the technologies?  How will their work practices and social dynamics reformulate themselves around a new system?  What will change, and what will stay the same?  What aspects of the project will fall into disuse, and what things might happen that I never could have anticipated?  I think by being intricately involved in a deployment, dedicated to making something that works for my collaborators, and willing to stick around to see what happens after the culmination of the project, I’ll have the opportunity to learn some really interesting things about what it might mean to have ICTs deliberately introduced into the practice of small health clinics.

So for now… I need to plan out that trip, set up housing, a schedule, line up my ducks, etc. I’ll test out some of my survey instruments: periodic surveys that I’ll repeat monthly throughout my stay as "checkpoints", and test out some of the equipment.  For this trip, I also have an undergraduate research assisstant, Emmanuel Owusu, with me.  We’ve been working on a first cut of "ClaimMobile", the application, so we’ll demo that for the partners, and get some initial feedback from the users on how it looks, how the form should be formatted, and everything, so we can start finalizing a digital equivalent of the paper form.  The hard part on this is actually formalizing in code what is currently a very implicit set of rules on what makes a valid claim and what doesn’t.

I think… none of this blog post makes any sense if you haven’t seen me present about my project. =) Oh well.

The long and short of it is that I’m in Uganda for a month, and I’ll be going out again for a year in January…

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Epocrates for developing countries?

So I’m talking to my doctor about possible drug interactions between various prescriptions and he pulls out a… (drum roll) palm treo. Oh okay so that’s probably not a major revelation.. doctors love Palm devices and have loved them pretty much since 3COM started making them back in the 90s. (Can I say that yet? Back in the 90s?) And of course my immediate reaction is to ask him what software he uses, mentioning that I’m looking into what software might be useful for rural clinics in developing countries (e.g. Ghana and Uganda and D.R. Congo). He replied: you only need one! It’s called Epocrates.. like Hippocrates, but with an ‘e’! Clever, huh? (Okay I’m paraphrasing, but only a tiny tiny bit.) Then he proceeded to show me a drug database, a symptoms database, and a diagnosis database, all hyperlinked together.

Of course – before everyone goes off running to deliver this very fine product to the masses of doctors in developing countries, there are a couple of catches. The data is very much geared towards doctors in the US, which has a number of implications. 1) Only the drugs that are available in the US are listed, and then with the US names. So, for example, many of the newer malaria medications which haven’t been approved in the US (like Coartem) won’t be there. And other drugs like paracetamol (as it is known in the UK and former British colonies like Ghana and Uganda) will be listed as acetaminophen. 2) There’s a yearly recurring cost of $100. Of course, this might not be out of reach for these doctors, and certainly is about equivalent in price to the paper versions of these reference guides, and about 1000 times more portable.. 3) The pathology is different – a doctor in the US wouldn’t expect TB, where a doctor in Uganda or Ghana would know to look for TB symptoms.

I bring all this up because I spent part of this past summer in Uganda with the 2007 East Africa Blum Fellows visiting some of the Uganda Health Information Network (UHIN) deployment sites in Lyantonde and Rakai. What struck me most was not the specific programs offered by the project (digital submission of health outpatient statistics, and dissemination of malaria and pediatric health information), but rather how they appropriated the devices, installing and sharing their own applications, and using the Excel application to track inventory and patient logs. They just drink up this data, reading whatever they can get to learn more about how they can care for the wide variety of conditions they see every day. So.. in addition to whatever information management functions I can put into place, I hope I can also help put more information in the hands of the doctors and clinicians and nurses I’m working with.

There’s of course still a lot of other issues to deal with – everything from power for recharging to the cost of the devices themselves (~$70 for a Palm, and $300 for a Palm+Mobile Treo) to maintenance and sustainability. I still want to try putting this type of information in their hands, with all of the appropriate warnings, as well as more locally specific information, like local health bulletins or Hesperian’s translated Where There is No Doctor series. Let me know if you have any suggestions for mobile health applications!