Innovative Mobile Technologies improving health in developing countries

Innovative Mobile Technologies improving health in developing countries

Professor Kristin BraaDepartment of Informatics

University of Oslo

The importance of mobile technology for developing countries

• There are 4,5 billion mobile phones

• 305 millions PC’s,• but only 11 million

hospital beds• The mobile is the

Internet device

The importance of the mobile phone to developing countries

• 79 mobile subscriptions per 100 inhabitants

• 25 PCs per 100 households

3

Data from the International Telecommunication Union (ITU)

79

25

0

10

20

30

40

50

60

70

80

2006 2007 2008 2009 2010 2011

Households with PC

Mobile subs

%

Diffusion of Mobiles and PCsin Developing Countries as of 2011

Case: IndiaMobiles exploding, few PCs

• 929 milling mobile subs in May 2012 (78%)• 142 million sub added in 2011

• 55 million PCs in use (2009)• 4,7 PCs per 100 inhabitants

• 4,2 fixed Internet connections per 100 households (2011)

• 121 million Internet users (2011) 11%, 97 million are active (at least once in a month)

• Internet usage penetration growth is only 19%• Broadband penetration 0,014%

4

Data from the International Telecommunication Union (ITU) Telecom Regulator of India (TRAI)Boston Consulting GroupInternet & Mobile Association of India

76

0

10

20

30

40

50

60

70

80

1998 2000 2002 2004 2006 2008 2010 2012

Mobile subs per 100 inhabitants (2012)

• HISP is a global action research network headed and initiated at the Dept. of Informatics, University of Oslo since 1994

• DHIS 2 is an open source software developed, customized and used for reporting, analysis and dissemination of health data for many health programs

• Shared and integrated data warehouse for essential health data: information for action

• Implemented in 30 countries, national standard in 12 countries, WHO endorsed

• Joint 3-donor (PEPFAR, Global Fund, Norad) effort to strengthen DHIS 2 use in countries

• UiO Innovation award 2013

Health Information Systems Program - DHIS2

United Nations Milleniun Development Goal indicators (2000)

• MDG 4 – Underweight rate of children under 5– Under 5, Infant Mortality Rate,– Under 1year measles immunisation coverage

• MDG5– Births attended by skilled midwives– Maternal Mortality Ratio

• MDG6– HIV (15-24 years) in ANC,– Malaria, TB prevalence, death and cure rates

• MDG8 – Essential drugs availability

DHIS 2 as an online national HIS- integrated repository for all health statistics

Action oriented multidisciplinary research

• Strengthening national health information systems

– Collaborating with Ministries of Health

• Building capacity locally– At present 32 PhD students worldwide. 20 graduated– PhD school– 5 international Masters program– DHIS Academy (East Africa, West Africa, Asia,

Latin America)

• Research theme: Implementation– Interoperability– Architect(ing)– Scaling

• Open source software development done in a global network

DHIS 2 Academy: Regional training program in East Africa, West Africa, Asia, Latin-America

Advanced DHIS 2 Academy, Entebbe, 4-13 June 2013

= National HIS deployment= National start-up / pilot = early national initiative or program-specific deployment

ECOWASRegionalDeployment

EACRegional

Deployment

Present in over 30 countries, 10 Indian states National standard in Kenya, Ghana, Uganda, Rwanda, Liberia, Nigeria, Sierra Leone, Gambia, Zanzibar, Malawi, Zimbawe

JavaSMS Android PC/laptop/tabletBrowser

Community /Villages

CommunityHealth Workers

Clinics

Districts /Hospitals

Extending the DHIS reach through mobiles

A suit of mobile applications fordifferent available infrastructure

• Voice calls• SMS (sent directly from the user)• Java client with SMS or data• Mobile browser (native/OperaMini)• Smartphone browser or app• Tablets browser or app• PCs with web browser & mobile data

Low resource constraints

• Sometimes no power, no roads• Expensive to buy good phones• Low end phones: cheap, simple, small

screens and limited usability • Leverage installed base of users’

phones?– Increases complexity: multiple operators, more

handsets, more training, private subscriptions

Data warehouse

DHIS 2

LMIS

HR EMR

Measles under 1 year coverage by district 2006(Measles doses given to children < 1 year / total population < 1 year)

74.781.3 79.0 80.7

89.594.4

80.0 79.9

93.6 93.8

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

ChakeChakeDistrict

Michew eniDistrict

MkoaniDistrict

WeteDistrict

CentralDistrict

North ADistrict

North BDistrict

SouthDistrict

UrbanDistrict

WestDistrict

Pemba Zone Unguja Zone

District

An

nu

al m

ea

sle

s c

ov

era

ge

%

Extract

Transform

Load

Data fromMobile devises

Data capture from paper forms

-Data mart-Meta data-Visualising tools

Dashboard

Graphs

Maps

Getting data in - Data warehousing Getting data out - Decision support systems

Web Portal

Mobile

• Kenya– National online HIS using mobile internet– Facility census SARA– PEPFAR reporting

• Ghana– Fast moving learning from Kenya– Limited resources

• Uganda– Maternal and neonatal death audits– Tracking of pregnant women– SMS reporting on eMTCT– ARV ordering

• Punjab– Mobile HIS reporting, 6000 health workers

• Zambia– 600 mobiles for malaria incidence reporting

Learning through network of action

Developing countries ≠ low-tech: Kenya

• Cloud-based – secure, fast deployment and easy to maintain

• Web-based flexible updating of the service

• HTML5 with offline-support• PC with mobile broadband• Support for mobile phones• Integrated messaging system connecting

the users• Sharing of advanced reports and analysis

with GIS support

Cloud basedservices

Mobilebroadband

Web-based

Country wide implementation

Offline support

ServerUnstable network

• Network coverage variability/instability requires offline capabilities

• When there is no coverage – store locally and submit later

Java-based mobile reporting in India

• Punjab – 6000 Auxiliary Nurse Midwives (ANMs) reporting weekly and monthly using the DHIS-Mobile Java client

SMS used as transport. Forms can be stored locally. State has purchased phones and pays for subscriptions.

DHIS2 is the state-wide national Health Information System.

Paper based reporting still happens and feeds into DHIS2.

NationalHIS

Database

Uganda ”Saving Mothers Giving Life”

09.04.2023 19

• Project in 4 districts in Uganda• National DHIS2-based infrastructure is used for reporting

most routine data from clinics • SMS reporting by Village Health Teams (CHWs)

SMS Broadcast Messages

Weekly reporting

Dashboard

Graphs

MapsMobile

Direct to

Send to 6767

Results

Results

Uganda: eMTCT - SMS Weekly Reporting

pmtct a.400.b.359.c.50.d.98.e.10.f.50.g.0.h.n.i.y

• Goal: Elimination of mother to child transmition of HIV• Rolling out to 2,400 Option B+ implementing service outlets

09.04.2023 24

Uganda – Mother/Child tracking• Integrated service for tracking mothers and

children through pregancy-delivery-postnatal• 10 facilities. • PC, Tablets, Smart- and feature phones, SMS• Key challenges:

– Mothers access many clinics. Data is lost. Unclear responsibility for follow-up

– Fitting a common system into multiple clinic contexts, sizes and workflows

– Integrating community health workers into electronic system for follow-up, using SMS

– How to best remind mothers of appointments (SMS)– Maintaining privacy of data while sharing

• DHIS Tracker is used to implement the project ?

Find Person, Enroll and Add Relationship

DHIS on smartphones with offline support

Leverage on the social network

Mobile = communicate and share• The mobile is primarily a communication tool!• Don’t forget to improve communication, even if it is

the secondary goal of a specific mHealth project• Community features help create sustainability• Example: Closed User Group makes people

positive about project and acts as an attractor

Improving data quality through social media

Interpretations

• Charts, reports, maps can be shared with other users of DHIS 2

• Discussion forum open to all users to comment on the data

• Fostering communities of data use

Research agenda: Pilot to scale

Pilots Early decisions of solution type create path

dependencies

Principles for pilot to scale• Leverage existing systems – think national• Work with the Ministries of Health• Put servers online, but think offline… • Think scale already in the pilot phase• Support a range of mobile devices• Do not get locked in to one mobile operator• Use local resources to drive implementation• Work with partners – a network of action• Share the collected information!!

Rwanda

South Africa

Malawi

Tanzania

Burkina FasoIndia

Norway

HISP collaborative Network of Action

Health Information SystemsResearch, Implementation Development

Open Source Software DHIS2Sharing across the world

Capacity BuildingTraining, Education, Research

Botswana

Vietnam Togo

others Nigeria Liberia

Ghana

Sierra Leone

Gambia

Côte d’IvoirSri LankaMali

Bangladesh

Uganda

Partner contributionPSI, Pepfar, Global Fund

Use of DHIS for own reporting& development

Regional development West Africa & East Africa:

Kenya

High tech – low resource – big impact

www.dhis2.org

Thank you

Thank you

• High tech – low resource – big impact

• http://dhis2.org

Hich tech – low resources - big impact

LightweightBrowser

SMS

Android app or browser Tablet

PC/laptop

More f

lexibl

e

Regional data warehouses

• The West African Health Organization (WAHO) and the East African Community (EAC) are establishing regional data warehouses using DHIS2

• 15 (WAHO) and 5 (EAC) countries will routinely report on essential indicators to the regional database, enabling regional data analysis down to the sub-national level

• WAHO and EAC have begun networking in order to share experiences across the regions

HISP and DHIS 2 in 2013

• Recent developments:– Pepfar support to integrate partner

reporting/attribution– Global Fund collaboration on

country support for DHIS 2– CDC piloting DHIS 2 for Global

Health Security emergency response system

– PSI adopting DHIS 2 as their internal information system, incl. individual records

– Uganda is using DHIS 2 SMS for reporting maternal and neonatal deaths from the communities in SMGL districts

Working with the mobile operator• One or many operators?• Difficult to get operator buy-in during

pilot. Operators want scale and ARPU. • Who pays for subscriptions?

Reimbursement• Prepaid vs postpaid subscriptions• Cost control (limiting usage)• Closed User Groups with a single operator• Early decisions may create problems

when scaling

Where could operators help?• Mobile data packages

– We typically use very small data volumes, but in many countries data packages are required to use data. The cost of setting up data packages is too high, when only very small data volumes are used.

• Closed user groups– Providing free phone calls between health workers is

an efficient way to increase communication and improve the tracking of mothers. In an extreme case, a community health worker may not be able to call the health clinic, and the mother could die as a result of lack of mobile credits!

SMS Access• SMS Access

– SMS is still the most efficient mechanism to reach large number of health workers and patients, both for information and data collection.

– One of the most troublesome issues in many countries is to set up a stable SMS access with the same short number for all operators.

– Reverse charging of SMS. Receiving party pays (free for users).

Reimbursement and payment• Reimbursement and payment for services

– We have very good experience with solutions that reimburse the health workers automatically for their data reporting.

– The problem is that there are no common interfaces for such reimbursement and top-up for prepaid credits. This is a manual and labourous task.

• With mobile payment, health workers could also get their pay through their mobile. In many countries, this would provide a more stable and less corrupt way of pay health workers.

Use the mobile for the right thing• Are we using it just as a PC substitute?

– Short term: this seems like a good strategy. When paper and PC is difficult, use mobile to collect data

– Longer term: Mobile HIS solutions will live alongside the PC, but will cover different needs.

• What can the mobile do better than a PC?– Communication – always available– Reach masses with information – pervasive– Simple data entry and feedback tasks. Questions and

responses etc. – Urgent communication in crisis situation

Expanding the DHIS 2 reach through Mobile technology

A suit of mobile applications fordifferent available infrastructure (SMS, Java, Browser)

• Kenya– National online HIS using mobile Internet (DANIDA,

USAID funding, HMN framework approach)• Uganda

– SMGL pilot, national rollout, tracker (continuum of care), ARV logistics

• Punjab– Mobile HIS reporting,

6000 health workers• Zambia

– 600 mobiles for malaria incidence and stock reporting

• Malawi– Piloting browser vs application in 2

districts

Districts life cycle chart, Uganda

Deliveries by skilled birth attendant, Kenya

Malaria incidents and stock, Zambia

Using DHIS2 Mobile SMS client for real-time reporting from the

community

SMGL Village Health Team Weekly reporting in the 4 SMGL pilot districts