Smartphones and
Information Management for
Rural Health Care Clinics in
Africa
Melissa Ho (mho@ischool.berkeley.edu)
PhD Student, School of Information
“Global Development in Action” Student Symposium
Thursday, October 4, 2007
Blum Center for Developing Economies, UC Berkeley
Moving right along…
 A quick overview of the context
 Communications Infrastructure
 Healthcare Information Practices
 What is a smartphone?
 Research Framework
 Findings on the Ground
 Framing the Context
 Learning from Experience
 Proposing Solutions
CIA World Factbook
 Population: 30,262,610
 Infant Mortality Rate:
total: 67.22
deaths/1,000 live births
 HIV/AIDS prevalence:
4.1%
 Landlines: 108,100
(2006)
 Mobiles: 2.009 million
(2006)
Communications Context
Mobile GSM Coverage
Internet
Infrastructure
Map courtesy Eric Osiakwan
Africa ISP Association
Image composed from coverage maps
available on gsmworld.com
Decentralized Healthcare
Nakaseke
District Hospital
Semuto HCIV
Tasks
 Inventory
 Referrals
 Statistics
Ngoma HCIV
HCIII
HCIII
HCIII
HCIII
HCII
HCII
HCII
HCII
Obstacles
 Roads
 Staffing
 Power
 Finances
Output-based Aid (OBA) Voucher
Program
 Subsidized voucher for treatment of sexually
transmitted infections (STIs) with modified
syndromic and lab diagnostics
brand
barcode
sticker
price per
voucher
partner
or client
Marie Stopes International Uganda (MSI-U)
& Microcare Insurance Ltd.
Pay service
provider
avg 30
days
max 60
days
Submit
claims
Record
voucher
sales data
Clinics
(16 at start)
Submit
voucher to
provider
Provide STI
diagnosis and
treatment
Send
vouchers
Community
distributors
(44 at start)
Pay
cash
Clients
(+350 per month)
Sell vouchers
avg 15
days
max 45
days
Smart Phones





Electronic hand-held device
Functions as a mobile phone
Provides internet access
Has built-in keyboard
Additional capabilities:
 E-mail
 Word processing and
spreadsheets
 GPS
 Custom programs can be
installed
Why Phones in Rural Areas ?
 Already widely prevalent in developing regions
 Usage familiar to rural users
 Powerful enough to be used for computing resources,
rather than just communication – so possible PC
replacement for vertical tasks
 Suitable for rural areas: low power, robust, cheaper,
lower operating cost, use existing networks
 Integrated features: camera, GPS, audio
 Appropriate for use across multiple households
Rural Data Collection Problems
 Data frequently missing or incorrect or
contradictory. E.g. sex is male but pregnant is
yes on health form – very hard to validate after
the fact
 Forms are very long and frequently
incompletely filled – questions are not
prioritized if partially filled
 Data collected not rich enough – no audio,
pictures, GPS without specialized hardware
(and also not integrated)
What Can Smartphones Offer ? (1)
 Immediate Validation
 Correct data upon entry, and also crosscheck with other fields if
dependencies exist
 Dynamic Forms
 Reduce burden on health worker by asking only relevant
question based on previous answers, thus reducing chances of
errors
 Also makes partially filled forms more useful
 Richer Data collection
 Photos, audio input, GPS (entire medical record possible)
What Can Smartphones Offer ? (2)
 Auditability
 Audio samples can be used to double-check responses
 Transparency
 Generating reports of and viewing system-wide statistics and data
 Operation in disconnected areas
 Use only for computation, communication not necessary for collecting
data on the field
 Synchronization of data
 When connectivity is available, upload to central server over the
cellphone network either through multiple SMSes, or data packets
over GPRS, eVDO, etc.
Expected Results
 Increased data accuracy
 Improved data timeliness
 Reduction of burden on healthworkers
 Reduction of the number of times surveyors
have to be re-sent back into the field to redo
surveys because of errors
 Better organization of data
Framing the questions
Be reflexive - question what you think
you know and ask open-ended
questions
Observe - find out about their current
practices
Identifying Pain Points
 What are the current processes?
 What do health workers do on a day to day basis?
 What are the data collection and information management practices?
 Who are the key players?
 Is there a local “champion” and local collaborators?
 Who is using health information?
 What infrastructure is available?

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Do the health workers have fixed line or mobile phones?
How do they communicate with their superiors and subordinates?
How is information relayed using current infrastructure?
What communications infrastructure is available but not being leveraged?
 Metrics
 What metrics are important to the community?
 How do they currently evaluate their own successes?
Health Clinic Visits
Health Centers
(Nakaseke District)
OBA Uganda
(Mbarara District)
MOH
UHIN
(Kampala)
UHIN Deployment
(Rakai District)
Framing the Context: Nakaseke
 Infrastructure
 Health Centers
 Data Reporting
 Mobile Phone
Usage
Poor road infrastructure makes it difficult (and expensive)
to travel between the health clinics and the hospital
Hospitals and upper-level health centers often
have co-located water pumps for the community
Public health campaigns are carried out
through radio and posters like these
HCIV
HCIII
HCII
The Ministry of Health mandates monthly
and weekly reporting of outpatient statistics
This district hospital keeps all of the HMIS forms
from each of the health centers in its district here
Creating the reports…
 Data is collated from
hand-written patient
ledgers (sometimes
exercise books)
 Forms are completed in
triplicate
 Submitted within 3 days
of the end of the month
 Hand delivered to the
District hospital
One particular health center was very conscientious about recording
data and producing graphs to visualize trends
Aggregating Data
Mobile phone use in HCs
 Every health center has at least one
personal mobile phone
 Innovative charging solutions
 Current Uses
 Emergency reporting
 Submitting weekly HMIS forms
 Checking salary and drug order status
 Requesting transportation
airtime
security
 Clinical consultations
network coverage
Choosing a smartphone…
Learning from Others: Healthnet
Reference: Uganda Health Information Network IDRC Report, 2004 (http://www.healthnet.org/idrcreport.html)
A project champion
Report Generation
Paper and Digital Data
“Sometimes I use it as a torch”
Power Issues
 Power shortage
 Accessibility of relay
points
 Ownership
 Existing Hierarchies
 Duplicate Tasking
Appropriatable Technology
Lessons Learned
MoH
Nakaseke
District Hospital
Semuto HCIV
computers + broadband
Ngoma HCIV
computer + smartphone
HCIII
HCII
HCIII
HCII
HCIII
HCII
HCIII
HCII
smartphone + pdas
smartphone
or paper
Marie Stopes International Uganda (MSI-U)
& Microcare Insurance Ltd.
Pay service
provider
avg 30
days
max 60
days
Submit
claims
Record
voucher
sales data
Clinics
(16 at start)
Submit
voucher to
provider
Provide STI
diagnosis and
treatment
Send
vouchers
Community
distributors
(44 at start)
Pay
cash
Clients
(+350 per month)
Sell vouchers
avg 15
days
max 45
days
Structured Facility Survey
Conducted by Richard Lowe as part of a
separate evaluation project
Providers vary greatly:
 Facility+Infrastructure Differences
 Number of Clients
 Distance from Mbarara
Part of the process
 11/12 Complete claims
forms during patient
consultation
 Timely processing
7 days: 2/12
14-15 days: 7/12
30 days: 2/12
 4/12 have computer
training
 12/12 own a mobile
phone
Struggling to Participate
 Providers travel up to 3.5
hours to submit claim forms
 Fewer clients --> Infrequent
Submission
 6/12 providers claim that
delays in payment interferes
with ability to serve patients
 4/12 don’t know how many
claims have been rejected. 3
have not gotten feedback
Paper vs Digital
 Paper is a
powerless backup
 Authentication using
physical artifacts
 Flexibility
signatures
client
fingerprint
voucher
barcode
clinic
stamp
Open Questions
 Pushing verification to the client
 Eliminate simple errors
 Biometrics (e.g. fingerprint, photo) ?
 Paper and Digital
 Is there a low cost printing solution?
 Can we make the digital process advantageous for all parties?
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Training and Usability
Power
Privacy and Information Security
Sustainability, Scalability
Execution
 Co-design and Co-deploy
 Local collaboration is key to the sustainability and appropriate
design of the system
 Collaborating with Mbarara University to integrate solar power
into health centers
 Development
 Leverage computer scientists at Mbarara and Makarere
 Develop SmartForms in collaboration with people who will be
using them: records officers, nursing assistants, in-charges
 Training
 Develop training plan and information practices with local
stakeholders
 Specialized training for key
 Handoff of Maintenance integrated early in the project
Acknowledgements
 Thanks to all of the Blum East Africa Fellows,
especially Katrina, Mallory, Simon, and Admas for
letting me observe and participate in their project
 Thanks to Professors Kristi Raube, Sandra Dratler,
and Eric Brewer for faciliating this research
 Thanks to Ben Bellows, Richard Lowe, Francis
Somerwell, and all others at MSIU and Microcare
 Thanks to the Blum Center for Developing Regions for
inviting me to speak and financing this research