ictdchick

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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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!

Hi all,

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

It’s been a busy couple of weeks, with not nearly enough access to internet cafes!

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.

The culmination of our many many meetings was our presentations to the Ministry of Health and the Member of Parliament (MP) for Nakaseke district.  (Although admittedly the MP meeting was a bit of a surprise, so a bit extemporaneous.)  We had been spending our evenings in Luwero (the town near Nakaseke where we were staying) processing everything we learned, and our days visiting the health centers.  We interviewed the in-charges, nursing assistants, and records officers/assistants at 3-4 health centers a day, and asked about stock management, health information reporting, and the general challenges they each faced in their daily work.  Almost none of the lower health centers (HCIIs and HCIIIs) had power (”We use lamps”), but even in the HCs with power the staff had mobile phones.  In those cases, they charge the phone by sending it off overnight with a matatu (the public mini-bus system) driver for the price of 500 shillings.  Most people have nokia candybars that stay charged for about 4 days.

I’m impressed overall with the staff we’ve talked to, and with how well all of the health centers comply with the Ministry of Health’s health information reporting policies.  They each submit weekly reports on highly infectious diseases (sometimes by SMS) as well as more comprehensive (4 page) monthly reports on stock levels, outpatient population, and diagnoses. In Rakai (another district) they submit these reports via PDA and gprs - here, they submit on paper in person to the district hospital in Nakaseke.

You can check out our findings in the presentation we made to the MoH, along with some ideas for integrating smartphones into their existing system.  The presentations (ours and that of the ICT team) were well received, and we are all looking forward to further collaboration on a project proposal, and hopefully a pilot once we receive funding to move forward.  There’s a lot of questions left to be answered (how do we balance paper and digital records? What about power?) and a lot of work to be done, but I have high hopes that handheld computing and communication devices like smartphones can make a positive impact on healthcare in Africa!

I’ve been in Uganda for almost a week now, doing a needs assessment with the East Africa Blum Fellows smartphone team - on whether and how smartphones can be used in the context of healthcare in Uganda.  We’ve had meetings all over Kampala, with Satellife/Healthnet Uganda, the Ministry of Health, and various people at Makarere University.  See my flickr account for a photo diary.

My most productive meeting so far has been with Francis and Gerry at Microcare, Uganda’s largest insurance company.  Ben Bellows has been working with Microcare and Marie Stopes International on Output Based Aid (OBA), a voucher-based scheme for the delivery of STI treatment in the Mbarara district 6 hours drive west of Kampala (by the way, I just arrived in Mbarara yesterday). Ben and I (along with Mahad and Sonesh) have been talking about how to integrate smartphones into the voucher claims process and recently won a CITRIS award to fund the implementation of a pilot deployment.  So when I arrived in Kampala, I made plans to meet Microcare and MSI to talk about our plans.

What strikes me most about Gerry and Francis is how fast they think.  Having learned all about their insurance system, I asked why they didn’t use smart cards for the OBA program as well. In a flurry of conversation we realized that the smart cards are durable enough to be reused - and would be a useful platform for a new rural program promoting antenatal care.  Rather than using vouchers, which could be resold or appropriated, they will issue smart cards for the 9-month duration of the pregnancy, recording visits.  The "admission" into the program would be the cost of the smart card (about $1), and upon completion the patients would return the card in exchange for a small gift (we were thinking of baby socks).  Within five minutes of my question, we not only had a whole scheme worked out, we also had a name: Smart Delivery.  Using smartphones enabled with smart card readers we can set up a rural terminal such that transactions can be delivered efficently via SMS at extremely low cost. Within one hour, we had defined a protocol, and Francis had assigned the project to one of his software engineers (Microcare insources their work to a wholly owned software company in Chennai) and made plans to complete the work by June 15th.  I’ll keep you posted on what happens!  In the meantime, I’ve loaned them my two GPRS modems, so they will be testing the system using two PCs.  I’ll see what I can do to implement the smartphone version…although it’s been entertaining trying to figure out the APIs without access to the web for documentation!

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I recently (April 29, 2007) gave a talk to the Ghana Physicians and Surgeons Foundation (a group of Ghanaian doctors practicing in the US) at their annual African Healthcare Summit.

My slides are downloadable here (ppt, 10.5 MB).  I gave an introduction to TIER, talking about our work using long distance WiFi (WiLDnet) for the Aravind Eye Hospitals in India, then gave an overview of our project in Ghana. Just for a bit of context, I also presented a brief introduction to network infrastructure options in Ghana.

It was a great opportunity to meet many wonderful people, including my host Grace and the many doctors actively returning to Ghana on a regular basis to provide training and do rural outreaches. I’m really looking forward to working with all of them!