Dembbe Clinic WECARE Solar and Netbook Deployment

Kathe Medical Care Netbook Deployment

Barefoot Power PowaPak and Palm Treo Deployment

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.

• Daily WE CARE Solar Logsheet
• Daily Usage Log

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.

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.

From:  Laura Stachel

Cross-posted from wecaresolar.com
Hello friends and family,
I’ve been in Nigeria for 5 days and it’s been a whirlwind of activity and accomplishments. Please take a look at the WE CARE website: www.wecaresolar.com if you want some detailed updates. The solar project is phenomenal – the solar panels are being installed, wiring is being done, and lights will be up in the maternity ward, operating room, and labor and delivery by the end of Monday. We’ve also installed outlets to enable suctioning in the operating room, and ongoing battery charging for the walkie-talkies and LED headlamps. Nurses in ALL of the wards are using the LED headlamps, and I’m learning that they are no longer having to postpone critical nursing care due to lighting problems. So intravenous lines are being placed on time, babies are getting the antibiotics they need, and stress levels are going down. The new antenna for the walkie talkies has been installed, and the repeater will be put in place on Monday. Then I will test the system to
verify that the walkie talkies will extend for 12 miles. That means that all the hospital employees on call will be able to use them, not just the ones who live on the hospital grounds. I also met with a group of visiting American doctors and convinced them to donate surgical supplies to the labor and delivery ward.  Finally, I have been observing and working with hospital staff, who have asked me to initiate a meeting next week to review difficult cases with poor outcomes, and to promote improved standards of care. They see me as  an allie and have responded to my gentle criticisms of their care in the most productive way possible.

And for the most special surprise – I procured a solar powered blood bank refrigerator and solar panels for the laboratory today

I’m going to be visiting the ministry of health on Monday, because the hospital wants to have a celebration in honor of WE CARE on Wednesday.

I haven’t been sending out my field notes about hospital care as I have in the past. I have been witness to many sensitive things, and worry about publicizing this for the world to see. If you would like any of my notes for your personal perusal, just let me know. They are at least as detailed and moving as the ones I blogged a year ago.

Finally, some of you have asked me how to make donations.  If you have not had a chance to make a donation to the WE CARE project and would like to, the website will accommodate donations through PAYPAL for a tiny fee, or you can send a check to: WE CARE, 3009 Hillegass Ave, Berkeley, CA. 94705.

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

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 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.

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.

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!

Normally I’m pretty skeptical about missions. I mean really – what depth is there to going out to beaches over spring break and walking up to random strangers to tell them about God? It’s pure proselytization. But over the past few years I’ve been taking development classes and talking to people in Ghana, and I’ve realized that missions are not purely evangelical; many of the schools and hospitals in Africa are missions in which people have devoted their time and skills towards God’s mission of feeding the hungry, clothing the poor, and curing the sick. But still.. what can one do with two weeks? Short missions trips are always ultimately for the benefit of the person going and not to the community supposedly being served.

This trip was different. We gathered together as a multi-disciplinary group of people who wanted to go to Goma to listen to the people there, to hear what needs were there, and to serve in whatever way we could. We preached, installed wireless routers, and taught workshops on how to play with children. We even painted a mural! I really think we made a difference… and I can’t wait to go back.

For those of you that are interested, here’s the text of the talk I gave at the trip report:

First, I want to introduce you to Bizi, the medical engineer at HEAL Africa. Bizi was incredibly helpful, always smiling and always ready to help. His official job is to maintain and repair all of the medical equipment: incubators, oxygenators, etc. In one of my first interactions with him, he took me to visit a little premie in an incubator he was monitoring. He always referred to little Rebecca as “his” baby, checking on her often to make sure the incubator was still working, especially when the power went out. While he was there, he was also able to repair a second incubator, one that had been donated in 1976 to another hospital and re-donated to HEAL Africa recently. I could tell that his heart was very much broken with care for the shortage of functioning equipment – and the people unable to get adequate care as a result. Not only that, Bizi also strove to help people wherever and whenever he could.

I interacted with him mostly on the IT project. Together, we worked with the two IT administrators, Pytchen and Jacques, to set up a wireless link from the Jubilee conference center, to the main hospital grounds about 300 meters away. The hospital already has a wireless link to the local internet service provider, providing Internet to the 7 computers available in the “Internet Room”, as well as any laptops that want to connect using WiFi, but it’s not accessible in the main hospital It’s not in Bizi’s job description to help with the IT stuff, but he told me that he likes information technology, and he saw that I might have trouble communicating with Pytchen and Jacques with my limited French, and decided to step in. It’s this type of thing that made my time in Goma really stand out.

By this time I had already been in Africa for 3 months, trying to deploy IT solutions in Ghana and Uganda as part of my dissertation research. I’m a PhD student in the School of Information at UC Berkeley, investigating the best uses of communications infrastructure for healthcare in Africa. So I’m familiar with some of the resource shortages in rural Africa. Although my time in Uganda was incredibly productive, my time in Ghana was riddled with bureaucratic, technical, and logisitical struggles. By the time I arrived in Goma, I was frustrated and had almost become cynical about working in Africa, sure that any efforts that I put in would ultimately be weighed down by people trying to get their own piece of development money coming from the West.

Meeting Bizi after this was so encouraging to me – to see someone not focused on his own gain, but instead focused on helping HEAL Africa be everything HEAL Africa could be for Goma, and on being a blessing to his community. Together, we set up a wireless router in the Jubilee Center, and another just above his office. The second one had to be placed about 6 feet above the roof. Lacking telekinetic powers to make it float up there, Bizi came up with a great solution: he pulled a broken IV stand out of the scrap pile and constructed a pole on which we could set up the antenna. A trip to the nuts and bolts market later, we had a link set up. I couldn’t have done it without his willingness to help.

And that is what struck me about HEAL Africa as a whole. Not only was everyone so willing to help, but HEAL Africa is an environment where people feel encouraged to start projects helping others, and to pitch in and help other people realize their own visions. It is a place of hope and restoration, where people that have hope can see real ways in which they can make a concrete contribution. I was so encouraged to see how HEAL Africa mobilized in a way such that even for such a short trip, our team was able to really serve with our gifts, teaching, preaching, painting, and using technology. I was so encouraged to see all the programs HEAL Africa has running, and to meet the many Congolese people that were so engaged in running the programs. I was so encouraged by the hope and the joy in the hearts of the patients of HEAL Africa, some of whom had been there for years, and all of whom were suffering greatly. Their hope was rooted in faith and a hope for restoration.

Given the weight of what we saw, and some not-so-great experiences in Ghana prior to my arrival, a couple of my thoughtful friends have asked if I was discouraged about trying to get work done in Africa. My response is always that my time in Congo was very restorative and grounding – and reminded me who I’m doing my PhD for, and why my heart is so broken for the people of sub-saharan Africa. I learned the value and the hope entailed in an environment supportive of innovation and progress. And I was restored because I felt genuinely loved by my teammates and the people at HEAL Africa.

I gave a presentation at the Blum Student Symposium last Thursday.

For anyone that’s interested, the slides (65MB) are downloadable here:

http://tier.cs.berkeley.edu/~melissa/blum-symposium-oct-04-07.ppt

The talk was about current health information practices in rural health clinics in Uganda, how PDAs have been integrated into a particular district, and our projections for what we’re working on now.

The future symposiums look really interesting (See Blum Event Calendar for times and locations):

Legal Aid Organizations and the Rule of Law in Sudan
Presentation by Mark Massoud, Jurisprudence and Social Policy Program Graduate Student
Thursday, November 1st

Media and Development in Zambia
Presentation by Laura Hubbard, Visiting Faculty, Anthropology
Thursday, November 15

Reducing Rape and Mutilation in Darfur with Fuel Efficient Stoves
Presentation by Susan Amrose, Graduate Student, Energy & Resources Group
Thursday, November 29th

For those of you interested in my work in Goma, Congo, check out my team blog:
http://gomateam.blogspot.com

Also, for a more recent technical update, you can check out Eric Nguyen’s blog here:
http://mindtangle.net/2007/09/08/work-update/

For those of you interested in learning more about HEAL Africa, PBS is showing a documentary called Lumo on KQED Channel 9 on Tuesday, September 18 at 11:00 PM. (Those of you not in the Bay Area can check your local listings on the website: http://www.gomafilmproject.org/ ). My church (fpcberkeley.org) is also hosting a preview viewing on Sunday, September 16 at 7:00 PM in G 202.

So one Friday I set out with a mission: to set up all my phones with Areeba Data Services and Tigo GPRS/EDGE. I found the addresses of the head offices, figured out a route, and resolutely headed into the traffic.  Altogether the process was a lot more hassle than strictly necessary.  If they had just put the name of the access point on the website, I could have pretty much done all the work myself.  Instead, I spent three hours at Areeba and another hour at Tigo, trying to convince them that I knew perfectly well how to configure my own phones, no matter how many other know-it-alls had come into their office before.   At Tigo, I finally pulled out all four phones, handed one to the agent, and asked for the access point.  I managed to configure the three in my possession and get them working while she continued to poke around the preferences on my poor treo. Okay okay, to be fair, she was extremely helpful and friendly, and I’m altogether pretty happy with Tigo customer service.  With Areeba, however… the whole thing was some weird bureacratic process… and I’ve been warned that I might have to go through it again when they switchover the name of their networks to MTN (they were recently acquired). But to get to the interesting part:

How to Configure your GSM Mobile for GPRS:

As it turns out, neither Areeba nor Tigo require any authentication, nor any particular special configuration.  So, if you can find the GPRS settings on your phone (under Preferencs on Palm, and under Settings -> Connections on WM) then you just need to set up a connection pointing to the right access point, and to make sure that the phone uses the right access point settings for whatever SIM card you have inserted.  For Areeba, you actually do have to go to the head office, because they have to "activate" your GPRS service on the network, tied to the SIM, because they charge an activation fee of 50,000 cedis (5 Ghana cedis,  aprox. $6).

Areeba Data Services
Access Point: internet.areeba.com.gh
SIM Card: 15,000 cedis, including 10,000 airtime
Airtime: 45,000 minimum balance recommended
Activation: 50,000 cedis
Charges: 19.89 cedis/kb

Tigo GPRS/EDGE
Access Point: web.tigo.com.gh
Authentication: not required, but if necessary you can use User:web/Pass:webhost
SIM Card: 15,000 cedis, including 10,000 airtime
Airtime: no recommendation (I purchased 40,000)
Activation: none
Charges: 9.2 cedis/kb

It’s been noted to me that Areeba is more expensive because they are bigger. Of course – if you are a Tigo customer and most people are on Areeba you are paying a lot more in airtime charges than Areeba customers that never talk to Tigo customers. So I guess it just depends on what your friends have. Or you can be like a lot of the people I see here and just have two SIM cards, one on each network.

Areeba was a bit of a struggle, so if you want to just be a casual Internet user, I suggest trying Tigo or possibly Kasapa (I haven’t tried Kasapa though!).  They are considerably larger and seem to have set up a bureacracy around customer service.  I was given a number and told to head upstairs, where I periodically shifted seats towards the front of the line and I severely objected to their as-yet-unexplained need to make a copy of my driver’s license.  I wasn’t afraid they were going to steal it – I just felt it was completely unnecessary for them to take it.  From there I talked to one agent, who asked me to wait while she served the other customers because it would take 40 minutes to configure my phone.  I waited, and at the end of 20 minutes was told to fill out a form and go pay the activation fee.  When I also mentioned that I needed another SIM card and air time… I was told that I couldn’t pay for the activation until I had a signature on the form with the sim card number and that I had to buy the airtime at yet another counter. But I couldn’t get the signature until I had paid for the SIM card.  Three visits to various cashiers, and one more visit to the customer service rep later, I finally sat down, with the appropriate signatures and lots of money paid to configure the phones.  After that it was relatively simple – she did some things on her computer to authorize my SIM chip, poked around and configured a phone, turned it off and on, and picked yahoo.com to show me that it worked.  I was a little miffed because Yahoo.com is not exactly a small page (m.yahoo.com is okay) and I was obviously paying for the download, so I stopped the page load and picked up m.gmail.com instead, sans images. The end result though!  I can now check my email even when the power goes out.  Ah the miracles of technology!

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This week I am back in Mbarara, currently using the computer science lab (which is empty because the students are all doing exams now), but also meeting with various professors here (again!) and working with Ben and Richard on the Smartphones for OBA project.

The major update is that we are now collaborating with the Faculty of Science at Mbarara (Physics Dept) to figure out solar power options for the health clinics participating in the OBA program. They are currently engaged in research evaluating the degradation of imported solar panels and are the perfect collaborators for this project. They also have experience with circuit-soldering, so they’ll try to use Manuel’s solar charge controllers both for their own experiments and our project.

We also visited the Marie Stopes International Uganda office and one of the Marie Stopes Uganda clinics. They are currently using the VMUS database developed by Microcare, and have two people entering the data from the (triplicate-carbon-copy) forms that are collected from the various clinics participating in the OBA program. Right now the system is down, so the forms are piling up, and they are entering the data into Excel, so they can process the reimbursements. I’ll head back there today or tomorrow to hammer on the SmartForm and figure out exactly what it should look like. At the clinic we spoke to Steven about his experience participating in the program. The major issues he identified are timeliness of reimbursement processing, limitations on the range of treatment options (if someone is diagnosed with a non-STI bacterial infection then they have to pay for treatment in addition to what they paid for the voucher, although I think the consult is covered), and patients coming in with vouchers that clearly don’t have an STI, and therefore are not eligible for subsidized treatment.  So there is a need for better and clearer marketing.  Richard suggested giving distributors placards that (literate) patients can read so they know what services the voucher will cover.  They also have problems with people going to multiple centers, and not having documentation for previous visits, or buying multiple vouchers and having tests done unnecessarily.   We hope that with the SmartForms project we’ll be able to address some of these issues, by making voucher records more accessible, and improving the communications process around the form submissions.  There’s lots of ideas flying around and a lot of work to do!

For the rest of the week (before I take off for Ghana) Richard and Ben and I will be visiting the various health clinics and talking to them about the project, getting a feel for their willingness/interest, as well as the environment in which the phones would be deployed.  We’ll start testing/piloting in August when I get back.