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.

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On PRI’s The World

Solar medical system
http://www.pri.org/business/social-entrepreneurs/solar-energy-clinics1583.html

A self-contained, solar-powered system for operating rooms ensure clinics in the developing world aren’t impaired by blackouts.

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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.

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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.

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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.

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It’s part of an interesting new direction for technology research – instead of just building faster, more high-resolution (and more expensive) devices, people are working on ways to build low cost devices that are more robust, can be mass produced, and can provide good enough information for primary triage.

On another note, these devices (as the economist article posits) could be well deployed with a good mobile-phone-based data collection system – collecting not just text and numbers, but images as well.

As part of the evaluation for the Uganda OBA project, Ben Bellows and his collaborators at Makarere University are conducting a household survey in the coverage area of the project and in a similar control area. As part of this survey they have to also do sexually transmitted infection (STI) testing, trying to determine the actual prevalence of STIs and not just an estimate based on who comes in for diagnosis and treatment. Can you imagine how much easier and verifiable these surveys would be if 1) the data collection could be done electronically, and 2) digital media for the testing could be integrated into the data collection records? Not that all diagnoses could be done with cell-phone microscopy, and you still need careful sample and slide preparation. But it’s still something to think about…

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• Displaced Fleeing War in Somalia Face Humanitarian Crisis
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• Drug-Resistant Tuberculosis Spreads As New Drugs Go Untested
• Expanded Use of Nutrient Dense Ready-to-Use Foods Crucial for Reducing Childhood Malnutrition
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• Civilians Caught Between Armed Groups in Central African Republic
• As Chechen Conflict Ebbs, Critical Humanitarian Needs Still Remain

Several of these are familiar to me through a combination of limited media coverage and personal contact. Malnutrition is a big one – while much effort has gone into funding for AIDS anti-retrovirals and other drugs, it’s been shown that availability of medicine often does not help without simultaneously pursuing proper nutrition. Likewise for a number of other indicators – malnutrition in children affects their lifespan, their learning ability, and their health. Schools that provide hot lunch for children – in both developing countries and developed countries – see increased attendance.

MD-resistant TB caught my attention because I’m in the middle of reading Tracy Kidder’s Mountain Beyond Mountains, a biography of Paul Farmer and Jim Kim (of Partners in Health). In Peru, where the DOTS program was implemented rigorously, they saw an outbreak of MDR-TB resulting from mismanagement of TB cases whose treatment fell outside of the “cost-effective” limitations of the DOTS program. They’ve made inroads in reducing the cost of second-line treatments, but as TB strains resistant to existing drugs appear, the costs of treating TB goes up. The question of financial sustainability in health is always tricky, making it difficult for health policies to advocate treatment of “rare” cases. Investment in research takes a long view – expensive efforts now to successfully treat MDR-TB cases today will result in lowered costs later on. Failing to treat today’s cases only pushes the need until tomorrow, when a few cases could multiply into an epidemic.

Having recently visited the HEAL Africa hospital in D.R. Congo, I’m still getting updates on the graveness of the situation there, in which several armies (Nkunda’s rebel troops, UN/MONUC peacekeeping forces, Congolese Army, Interahamwe, and more) are engaged in ethnic-and-poverty driven fighting. There’s been increased coverage recently, especially on BBC News, due to recent (i.e. starting in the weeks just after I left) increased instability. Refugees are fleeing to Goma and across the border to Uganda. Despite the danger, a team of medical practitioners from HEAL Africa continues their outreaches to rural areas, treating soldiers and villagers alike. Yet these new developments are only part of the story – even when things are relatively peaceful, the Congolese people of North Kivu (including Goma) experience atrocities daily, often perpetrated by the very people that are supposed to protect them – the Congolese army. Yet – precisely because this has been an everyday situation for a number of years/decades, these stories are not told, nor do we care to do anything about it. To hear the stories is to take on a responsibility, an obligation to care, but instead we prefer not to know about things we think we cannot control, we prefer not to know that human beings are capable of doing such horrible things to each other. I prefer to know – because I think we -do- have the power to change things, to consider our place in this world, and to want this world to be a better place. I think the world would be a better place if more people actively and genuinely want peace on earth, don’t you?

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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!

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And this is why I work in Africa…

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