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ABC 7: Phones used to solve medical issues in Africa

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Rickshaw Traffic in Dhaka, Bangladesh

This update is cross-posted on the FrontlineSMS:Medic website.

Good afternoon, world!  Just in case you forgot, my name is Nadim Mahmud and I am serving as the Research Director at FrontlineSMS:Medic.  Our program has been expanding rapidly throughout Africa over the past several months, and this summer marked our official foray into South Asia.  Back in February, we were contacted by an organization called the Smiling Sun Franchise Program (SSFP) inquiring about communication solutions for community service providers (CSPs).  SSFP is a USAID-funded project based out of Dhaka, Bangladesh that seeks to improve the standard of care in over 300 clinics throughout the country.  Working with nearly three dozen NGOs, the goal of the project is to help clinics become self-sustainable and successfully wean them off of foreign aid money.  Utilizing CSPs to bridge care between patient and physician, the clinics under the SSFP umbrella chiefly provide family planning and maternal/child health services.

CSPs are SSFP’s equivalent of the community health workers (CHWs) that we write about so frequently.  Their list of responsibilities is extensive, but fortunately their dedication to their work is equally matched.  They provide counseling services to newly married couples and expecting mothers, sell condoms and other family planning methods, play crucial roles in health education, and refer patients for antenatal/postnatal care and serious illnesses.  Each CSP manages between 200 and 300 households and many live at a considerable distance from their parent clinic.  Within the SSFP network, a huge challenge for rural clinics has been managing CSPs and monitoring the types of services that are being provided in their catchment area.  In the status quo, some 6,000 CSPs are reporting service statistics to clinics on a monthly basis.  Aggregating this data takes at least another 15 days and is prone to errors at several stages (there are seven layers of forms that need to be filled out at successive administrative tiers).  NGOs and SSFP headquarters receive data that is at the very least 45 days old.  As a result, they cannot respond effectively to changing dynamics in healthcare trends, inventory stock-outs, high patient dropout rates, etc.

A quick example of why this is problematic:  suppose SSFP conducts a nationwide clean-water educational campaign that is administered through their community educators and service promoters.  They would hope to see greater a disbursement of water purification tablets from their CSPs immediately after this campaign, but without reliable or timely reporting data they have no idea what the outcomes are.  This makes it difficult to decide whether or not the specific program was an effective use of resources, whether or not similar programs should be scrapped or modified, and sustainability margins consequently suffer.

CSP Focus Group - I'm the tall one in the back

To address problems like these, we planned to supply CSPs with java-enabled phones and utilize the FrontlineSMS Forms Client to allow them to fill out and send in daily reports on services provided.  Using this platform, the 42-field paper form currently being filled out by hand can be compressed down to a single text-message.  After a few days of brainstorming and getting up to speed on SSFP, I headed out to a few field sites to talk with clinic managers and CSPs and introduce the idea to them personally.  Once accustomed to the idea of a real-time communication network, the CSPs began to buzz with ideas exploring how it might be used.  One that was particularly popular involved a time-saving referral system:

Currently, CSPs that refer patients to clinics fill out a paper receipt that the patient is supposed to bring to the clinic.  Too often the patients do not show up.  Because of this high dropout rate, CSPs have been walking to the home of each referral patient a week after they refer them to check if they kept their appointment or not, a process that takes hours.  This is time that could otherwise be spent conducting health education sessions, promoting zinc tablet usage, water purification methods, or family planning services.  With FrontlineSMS, CSPs will provide patients with a paper receipt as before, but will also fill out a duplicate referral form on their cell phone and send this to the clinic.  When patients show up with their receipt, the clinic will match this up with the form received in FrontlineSMS.  If a record goes unmatched for a week, the clinic will send an SMS to the CSP with the name of the patient that needs to be checked on or nudged to visit the clinic.  This will allow CSPs to conduct targeted follow-ups rather than lose time seeing patients who have already received care.

Moving forward, we have selected two rural clinics to test out this system- one in Gopalpur and another in Rajoir.  In total, 90 CSPs at these clinics work to provide care to more than 180,000 people.  Beginning in early October, each clinic will be running a Huawei laptop with the latest install of FrontlineSMS (including a Bengali translation that we managed to complete).  Nokia has graciously agreed to provide 130 Nokia 2330s for these pilots, along with several free subscriptions for their Ovi web-based platform.  Because neither pilot site has internet access, exported CSP data will be sent to NGOs and SSFP headquarters using Ovi (summarized below).

Reporting Schema from CSP to SSFP Headquarters

I will be posting updates on these pilots as well as other projects in Bangladesh in the near future, but two more things before I sign off: 1) I would like to thank the Clinton Global Initiative for supporting my work this summer in Bangladesh, and 2) thanks again to Nokiafor providing the hardware needed to move these pilots forward.  Needless to say, we are all very excited to have this level of sponsorship for such a noble cause, and hope that our relationship with Nokia will continue to benefit clinics, community health workers, and patients across the globe.

\+/ Nadim

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The agenda is quite filled: after getting brought up to speed on SSFP’s current operations in the country, we will be working to customize forms for the respective clinics and hash out some of the applications for the communication network (who knows what will develop organically once the pilots begin, however). We have a meeting with Nokia to try and get a bulk rate/charitable organization discount on java phones. We need to procure netbooks and GSM modems from a separate provide. We have training sessions and site visits to conduct with the staff and CHWs throughout the peri-Dhaka region. And the timeline? Two weeks!

Also, for the sake of completeness, I’ve been in Mexico for the past six weeks working on a project unrelated to FrontlineSMS:Medic (but equally relevant to my career interests). That’s my excuse for the lack of updates.

Stay tuned Nadim \+/

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Updates on where I am/what’s going on forthcoming.

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This money will drive software development and implementation of FrontlineSMS:Medic throughout several sites in Africa and South Asia this summer.

Also, the current HopePhones tally is at 769, an amazing number of old phones donated. Keep it up!

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“I usually don’t like new things, but the name ‘Hope Phones’ sound pretty inspiring.  What is it, exactly?”

 Hope Phones is a massive cell phone recycling campaign that will help supply our FrontlineSMS:Medic pilot sites throughout the developing world.  We have graciously received support from thewirelesssource.com, which will be accepting, refurbishing, and reselling these phones.  We get a certain percentage of the resale value and use that capital to buy appropriate phones for our sites (non-profit, of course!). 

“I have so many old cell phones that I NEVER use.  How do I donate my old phones right now?”

 Go to www.hopephones.org and click on “donate phones.”  Tell us how many phones you want to donate, submit, print out the shipping label, package it all, and send it away!

“The recession has hit me pretty hard.  I don’t know if I can afford the postage.”

Not a problem- shipping is taken care of

“That’s great news, indeed.   But what is all of that nonsense on the front page?”

Those are the clinical sites that currently stand to benefit from Hope Phones donations.

There’s more infor on the site, but in the interest of time (have class in ten minutes!) I’m going to move on to the other point in the subject.

Quick Bangladesh update.  As you’ll see on the Hope Phones website, we’ve forged a partnership with the Smiling Sun Franchise Program in Bangladesh.  SSFP is a USAID-funded initiative that is serving many NGOs throughout Bangladesh to uniformly raise the quality of clinics and healthcare services in both rural and urban settings.  They have been interested in piloting FrontlineSMS:Medic as a communications bridge between clinical staff and community health workers, and in the past few weeks they have screened all of their clinics to find those best suited to the intervention.  They have  selected five clinics in the peri-Dhaka region to serve as pilots.  I’ll be heading over to Bangladesh in August to help with the setup, and I can’t wait!

\+/
Nadim

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I promise an extensive update after this next exam.  A lot of exciting things have been happening, and I’ve been remiss in keeping you informed.  Back to studying!

\+/
Nadim

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The UN Foundation recently put out a fairly comprehensive report summarizing mobile health (mHealth) initiatives around the globe.  Many of these have been anecdotally successful and give good reason for future optimism, but as Matt Over from the Center for Global Development so aptly pointed out, there have been very few rigorous evaluations of mHealth programs to date.  At best, we have measures of process outcomes (time saved, number of reported health events, patients enrolled, money saved, etc.), which are fantastic data but not necessarily indicative of the outcomes that are most important.  Whether the application is epidemiological surveillance, community health worker networking, or diagnostic treatment and support, an mHealth initiative fundamentally seeks to improve health- this is quantified by measures such as mortality and morbidity rates, cumulative disease incidence, etc.  What if the ability to remotely monitor patients leads to a complacency that actually increases morbidity and mortality in a patient community?  Suppose an epidemic tracking program that relies on remote forms receives 500 updates in a month, but there is a framing bias that confounds the results and ends up wasting resources?  I am certainly playing devil’s advocate to some degree, but the point is simply this: process measures lead us to believe that mHealth interventions should be improving population health outcomes, but until we measure them directly we don’t actually know.  It is vitally important to understand how a program with an accepted structure will predictably affect health outcomes.  Furthermore, if initiatives hope to scale, their efficacy must be proved beyond a shadow of a doubt.  Governments, partner organizations, donors, the medical community- these are just a sampling of the people that need to be convinced.

Given the recency of mHealth, it is understandable that process measures have been the data norm- they are focused on clear targets and can be acquired within a short period of time.  A randomized controlled trial that seeks to measure changes in population health, on the other hand, is an undertaking that requires an added degree of planning, resources, and time.  This is precisely what we at FrontlineSMS:Medic intend to do.  Without divulging any specifics prematurely, we have been talking to several major healthcare delivery and surveillance organizations in Bangladesh and should be finalizing our partnerships shortly.  The trial will be large in scale, randomized across several villages, and will take several years to complete.  As of now, it will be the first of its kind to quantify changes in population health outcomes as a result of a CHW-empowering texting program.  More to come.

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