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.

The most popular campaign over the past year is Warid’s Pakalast promotion, in which they offer 24 hours of “FREE CALLS” for 1000UGX (~$0.50 USD). Based on my surveys so far, people in charge of the private health facilities in my study spend a little more than 20,000 UGX (min 1,000 UGX, max 80,000 UGX) per week on airtime.   So, 7,000 per week for unlimited calling has the potential to change calling and mobile usage patterns, to change how people conduct business.

The impact is clear.  Where MTN has been the dominant provider by far in the past, my survey has shown that 47.5% of my survey respondents also own Warid lines.

The graph above depicts three columns.  The first column which mobile networks are used by each of the health service providers (HSPs) as their primary phone line.  The second indicates the distribution of mobile networks used for the secondary phone line (often swapped into the phone on demand, if the HSP only owns one phone). The final column indicates total ownership of phone lines, since many HSPs own more than two phone lines.

Most of my survey respondents own one (59.3%) or two (28.3%) mobile phones. On average each subject carries 1.93 SIM cards (i.e. phone lines) and 1.49 mobile phones.

People love this campaign.  And the other providers have scrambled to copy it, with Orange offering “free calls this festive season”. Zain’s February promotion is seasonally appropriate: “Share UNLIMITED LOVE this Valentines!”, but costs 2000UGX and is valid only from 6am to 6pm.  We all can only surmise that Warid is bleeding profits in order to increase their customer base…. with some success. It’s not uncommon to hear Ugandans say “Pakalast, pakalast” just for the sake of saying the word.  While “busha” means “free” in Ruyankole, “Pakalast” doesn’t really have any meaning – it’s just a made up word that makes us think of something that lasts.

In any case, I’ll fully admit I’ve been taking advantage of Pakalast to talk to my fiance when he’s been out in the field.  When a 10 minute conversation can cost 1000UGX, it’s pretty amazing to be able to talk for an hour and only pay 1000UGX. But it’s not without its hiccups.  Often we’ll activate the service (send an SMS with the word “paka” to 149) and it won’t actually start working until 30 min, or sometimes even 3-4 hours later.  Sometimes it won’t even work at all.  The notification messages are garbled. And yet, I’ve never heard a complaint about this from anyone.  TIA. This Is Africa.

But speaking of bleeding, on January 26th, I received a message from Warid: “Now send PAKA to 149 to get 24 hrs of pakalast at Ush 1,500. To get 4 days at Ush 4,500 send PAKA 3 to 149. For help dial 100.”

The price was increased by 500 to 1,500 per day.  Okay so now – for 7 days of pakalast, if you don’t plan ahead is 10,500 (~5.25USD), or if you do plan ahead you can pay for 5 days at once, and get 2 days for free at 7,500 (~3.75USD).  Now, bear in mind, that this expense is only useful for calling people on Warid, and by my estimates, at least 50% of users are not on Warid, and for those that are on Warid, their Warid lines are not active most of the time.  So this uses up 50% of their weekly average budget for airtime.  This will either 1) force everyone to switch to Warid, or 2) make pakalast too expensive…

So far it seems like people are still using Pakalast.  The alternative: is too expensive to consider.  It almost costs more to call another mobile in Uganda than it costs for me to call someone in the States.  And yet – I find that now I am not using Pakalast anymore.  Most of the people I’m calling are on MTN, and if I’m only doing one call in a day to Warid, there’s just no value in activating Pakalast.  It’s easier to just keep my call short.  Perhaps that’s good for Warid..

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…

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.

By far and away, MTN is the dominant operator. Zain/Celtel was the first to market, but as my Ugandan friends say “then they started cheating us, overcharging – we will not forget.” So when MTN arrived with giant masts, reliable infrastructure, and fair rates, the Ugandans switched en masse.

UTL is the government owned operator (they may be partially privatized, I would have to check), so they also carry the stigma of distrust of high prices, as well as perception of inadequate infrastructure. In my experience – their GPRS is great, EDGE is not so good, but their overall coverage is not as widespread as MTN or Zain.

Warid is a new arrival – as of about 2 years ago, and already they have a reputation for being an all-over network – that is what their billboards say (if you have time, browse my flickr photos from fall 2008). They don’t have huge market share yet but people say they will make gains. In the meantime, they are also entering the broadband market, offering low cost Internet services via a city-wide WiMax network at less than $100/month with minimal installation costs. Revolutionary in an area where VSAT is the norm.

Orange. Another provide means more competition. Will it force an existing provider out of business by driving prices lower? Will more money go into infrastructure rollout in rural areas?

Another extremely important aspect of telecommunications rollout in Uganda is the Uganda Communication Commission’s rural communications development fund, the RCDF. Using part of the income from the taxes on the voice communications, take bids from the mobile phone operators to fund projects to develop unreached rural areas that don’t have mobile coverage yet – and might not be a viable market normally. I think it is structured well here, with a good balance of investment in innovation and practical deployment. Orange has the potential to be another player here, if they are willing to participate in Uganda’s development, and not just trying to tap the mobile phone market. The two can be mutually beneficial. We shall see.