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11/9/2012

THE IMPACT AND SUSTAINABILITY OF MOBILE TECHNOLOGY FOR HEALTH CARE DELIVERY IN MALAWI

How many senses do we have? Acknowledgements: Mr. Kumwenda - supervisor Dr. Maureen Chirwa MACRA Organising committee Family

ICT Week 2012

KUNTIYA Kumbukani Website: www.kkuntiya.tripod.com Wordpress: www.kkuntiya.wordpress.com Skype: kuntiya-k Email: kkuntiya@yahoo.com November 2012

Contents
1. 2. 3. 4. 5. 6. 7.

1. Introduction
Report of a study on the evaluation of mobile technology projects undertaken by UNICEF, Evangelical Association of Malawi (EAM), and FrontlineSMS Medic Evaluating effectiveness, impact and sustainability of mobile technology as a tool for healthcare service delivery in Malawi Staff shortages in our health facilities.

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Introduction Study Background Study sites Problem Statement & Study Aim
4.1 Study Objectives

Methodology Study Limitations & Challenges Results 8. Discussion 9. Conclusion 10. Recommendations 11. References

2. Study Background
Population over 14 million Health challenges like HIV/AIDS, maternal health Low numbers of health workers Inadequate health facilities, long distances Community Health Workers - Home Based Care, CBOs Solution mobile technology projects by

3.1 UNICEFs RapidSMS


3 pilot sites in Kasungu, Salima and Dedza for nutrition surveillance Address issues

UNICEFs RapidSMS Mobile Technology project by EAM FrontlineSMS Medic at Namitete

Slow data transmission Incomplete and poor quality data sets High operational costs Low levels of stakeholder ownership Solution: RapidSMS SMS + Internet Rolled out in 2009
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3.1 UNICEFs RapidSMS

3.1 RapidSMS Project

Objectives
Identify possible improvements in data transmission and quality by using mobile technology Quantify the quality and transmission improvements Customize RapidSMS for use with the existing INFSS system. Adapt, if necessary, for national roll-out
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3.2 EAM Mobile Technology Project


Pilot - 2008, EAM in partnership with Tearfund UK 2 sites at Malindi and Nkope health centre Volunteers trained in HBC + Zain payphones Phones used for communication + business Facility level 2 sites equipped with telephone equipment

3.2 EAM Mobile Technology Project


Aim - strengthening the referral system Objectives:


Improve the quality of care provided by the HBC volunteers; Help the volunteers generate income from the phones for their sustainability; Offer a technological solution that effectively supports ICT related to health services

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3.2 EAM Mobile Technology Project

3.3 FrontlineSMS: Medic


Relies on free open source software platform running FrontlineSMS coupled with GSM technology (dongle) SMS communication between hospital staff and CHWs 1 laptop computer acting as communication hub linked to 75 CHWs Major site - Namitete (St. Gabriel Hospital)

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3.3 FrontlineSMS: Medic

3.3 FrontLine SMS Project

Usage:
remote requests for medications notification of patient deaths appointment reminders treatment adherence reminders patient or CHW queries requests for acute care replenishing CHWs SMS airtime

Aimed at increasing efficiency of CHWs maximizing productivity


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4. Problem Statement & Study Aim

Why the study?


No collective and independent studies No literature that could be used to scale up/replicate projects Implemented in isolation Most evaluations (if any) published externally academic institutions Potential behind mobile technology

Aim - determine impact of mobile technology usage for health care service delivery using the pilot projects
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4.1 Study Objectives


Investigate the effectiveness and impact of mobile technology projects for health service delivery; Analyse cost-benefits and sustainability of mobile technologies in health service delivery in Malawi; and Investigate the process and strategies used to implement mobile technology projects for health care in Malawi.

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4.1.1 Effectiveness and impact

Considering:
Cuts in delivery costs and time S/LT Remote service delivery vs normal service delivery Effect on the community health workers Effect on the livelihood of the HBC volunteers, CHWs Comparison of technology and non technology(control sites)
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4.1.2 Cost-benefit and sustainability


Benefits/costs that came about Technology and activity appropriateness Phase out preparedness mechanisms for sustainability

4.1.3 Process and strategies

Considered:
Beneficiary targeting Site identification Activity accessibility Project delivery - right form? Sufficiency of pre-project activities i.e. briefing, mobilisation, training Project activity implementation Limitations and mitigation factors Recommendation for replication
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5. Methodology
Type of Study Evaluation Used both quantitative and qualitative research methods Sampling - 1 site randomly picked per organization

5.1 Data Collection


Key Informant Interviews and Focus Group Discussions Examined records and observations at facility level by utilizing a checklist In depth interviews

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6. Study Limitations and Challenges


Non availability of recorded data No external funding data collection longer than anticipated Environment for data collection hospitals (disturbances) Time frame limited

7. Results
52 participants F=25, M=27 Age range 19 to 50 years Each of the participating project area had on average 10 participants At non technology level - 26 participants

No compromise on results

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7. Results

7. 1.1 Results (Impact) - RapidSMS


Data transmission delays cut down from over 2 months to immediately Cut in transport costs - data forms no longer taken to Lilongwe physically Responses immediate feedback data quality improved Data entry & analysis costs reduced to almost zero automatically by system

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7. 1.2 Results (Impact) - EAM


7.1.2 Results (Impact) -EAM


35,000.00 30,000.00

Travel costs and delays reduced by both community health workers and hospital staff K200 K20 Used to spend almost whole day away to the hospital but now seconds on the phone Medical assistant managed to cut down by 100% on all in hospital travel requirements Empowerment of HBC members through effective patient registration and referral Cuts in travel times by over 50% by Medical Assistant and HBC supervisor - conduct supervision/conduct outreach clinics CBOs were able to use part of the proceeds to buy basic items and medicine for the home based care patients
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25,000.00 20,000.00 15,000.00 10,000.00

5,000.00 Total Health Total Business

April 975.00 3,057.50

May 740.00

June 517.50

July 280.00

Aug 500.00

Sept 500.00

Oct 630.00

Nov 600.00

Dec 400.00

28 21,712.50 28,617.70 31,475.00 27,635.00 15,712.50 27,535.00 10,732.50 10,090.00

7. 1.2 Results (Impact) -EAM


CBO Name Mkadabwi Chikomwe Nkuli Mwalembe Mwanyama Lusalumwe Chiwalo Illiyoni Total Registered Patients 78 71 70 60 42 172 124 78 695 Referred Patients 16 48 4 9 1 4 70 20 172 % 21% 68% 6% 15% 2% 2% 56% 26% 25% 29

7. 1.3 Results (Impact) - Namitete


Message Content Patient Reporting or Referrals Request for SMS Credits Reporting Symptoms Other Request for Help Patient Death Notification Meetings Requesting Supplies Phone Problems Total Number of Percent Messages of Total 410 30.83% 219 16.47% 199 14.96% 173 13.01% 107 8.05% 75 5.64% 60 4.51% 59 4.44% 28 2.11% 30 1330

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7.1.3. Results (Impact) - Namitete


Department Pre-pilot TB 100 patients enrolled Post-pilot % Increase 200 patients enrolled 100%

7.2.1 Results Cost-Benefit & Sustainability RapidSMS


Considerable costs server, mobile phones, internet presence, toll free number Reduced delays in data transmission Improved data quality - national level @ 2.7% (n=517) Pre-project phase needed data entry & analysis, re-entering of data - automation Privacy and immediate attention Control over drop outs & was easy to follow up

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ART

168% 25 67 reports/m reports/mo onth nth


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7.2.2 Results Cost-Benefit & Sustainability - EAM


Costs: payphones, PABX installation at Malindi, HBC training Enhancing capacity building & infrastructure Increase in patient registration, referral & follow up Increased CBO income base Easy communication & networking No privacy - stationed at public places Phones deployed along with ULCHs

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7.2.3 Results Cost-Benefit & Sustainability - Namitete


Costs: Laptop + GSM, mobile phones Constant breakdown of phones and solar chargers Reduced costs of data transmission to the hospital 5Kms/bicycle Timely response to CHWs requests for support or ambulance services Patients felt very closer to hospital care Provision of airtime by hospital Provision of phones contributed towards easy communication & networking Recharge of phones a burden to CHWs Privacy and immediate attention Easy technology for both (automated system) Single laptop a hassle move round delivering messages
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7.3.1 Results Process & Strategies


All projects had a shortfall in terms of the way they were designed Likely contribution to the shortfalls that some of them encountered.

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Criteria

Project

RapidSMS Under 5 visiting Growth Monitoring Centres (HSAs) Site UNICEF implementation districts identificatio purposely selected with n various reporting trends Accessibilit Under five children and y of guardians/parents
Targeting services Delivery in Yes right format Pre project activities

EAM Community based structures CBOs and volunteers Existing partnership through EAM and CHAM facilities Both home based care patients and general community Yes, privacy of patients compromised for some patients Training provided to users, briefing to stakeholders, minimal on joint project design Joint between beneficiary and implementers EAM provided funding including operational costs High cost of equipment CBOs stopping activities at end of pilot phase High staff retention Completion from other sources of communication (not sorted out as pilot phase closed) Nothing project phased out

FrontlineSMS Community based structures CHWs Existing collaboration between funders and project site Home based care patients Yes, privacy of patients promoted Training provided to users, briefing to stakeholders, and ongoing project activities Joint implementation and is still going on Use of recycled phones, Use of solar chargers high cost for recharging, transport problems for CHWs to conduct home visits Network problems phones

8. Discussion

Effectiveness and impact of projects


time savings cost savings Additional or available resources

Training provided to users, briefing to stakeholders

Activity Joint implementation by implementa University of Columbia, UNICEF tion and Bunda College Limitations High cost of SMSing, High cost & Mitigation of equipment (computer and

Reinforces international campaigns and other studies and compares well RapidSMS - great potential for achieving greater effectiveness

internet connection), availability of phones amongst HSAs Availability of electricity for the server

Recommen dations for replication

Provision of toll free number Computers and internet procured by UNICEF Recommended but cost of Expensive to procure project internet might not be sustainable materials (pay phones) to most sites, computer software needs some customization

New phones acquired Network upgraded Highly recommended, cheap to implement


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reduced delays in data transmission improved data quality reduced manpower requirement reduced participant dropout rates improved reporting rates
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8. Discussion
More services deployed palliative care at Namitete Seeing more patients Additional costs to beneficiaries phone recharging Sustainability and ownership problems externally funded, academic institutions Capital outlay EAM vs UNICEF and FrontLine SMS

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9. Conclusion

First of its kind All have contributed towards impact Both patients and care givers appreciated introduction improvements in care, qlty + qty Reduction in stigma privacy Advanced care acquired easily call ambulance Drop outs low and easily traced (TB + ART) Report generation easy RapidSMS + FrontLineSMS No collaboration amongst stakeholders No standards set out by government/regulator i.e pilots, pilots for how long? Beneficiary protection Solution in itself and not part of the solution wrong Sustaining the momentum - challenge

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10. 2 Recommendations - Govt


MoH take a leading role to facilitate stocktaking and awareness Establish minimum standards Promote adoption and usage of mobile technology for social services - MACRA Reduction of ICT costs - removal of tax on ICT equipment Supporting academic/research institutions contributing towards attainment of MDGs (mine was turned down by )

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10. 3 Recommendations Implementers/Funders


Formal forum should be established share any updates and collaborate efforts Engage MNOs innovations, negotiate for any discounts i.e. social responsibility initiatives (CallDoc) Social marketing telecentres Exit strategies - safeguard sustainability; Case study of all the projects - learning and documentation purposes

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10. 4 Recommendations Community Members


IGAs - compliment towards cost of running projects i.e. buying airtime, recharging phone batteries More male involvement

11. References

Tearfund UK, Communication Technology Project Malawi Feasibility Study, December 2006 Broadhead R.L. and Muula A.S. Creating a medical school for Malawi: problems and achievements, Biomedical Journal 2002 Nadim Mahmud, Joce Rodriguez, Josh Nesbit, Mobiles in Malawi: A text-based intervention to bridge the patient-physician gap in the rural developing world, Global Pulse, Vol. 6, 2010 Karlstad University, Proceedings of 1st International Conference on M4D, December 2008 Vital Wave Consulting. mHealth for Development: The Opportunity of Mobile Technology for Healthcare in the Developing World. Washington, D.C. and Berkshire, UK: UN Foundation-Vodafone Foundation Partnership, 2009 Mobile Health, http://www.wikipedia.org/wiki/mhealth, Accessed 4 July 2010, 11.00am Sheila Kinkade, and Katrina Verclas,Wireless Technology for Social Change:Trends in Mobile Use by NGOs, United Nations Foundation - Vodafone Foundation Partnership, 2008 Smith MK and Henderson-Andrade N. Facing the health worker crisis in developing countries: a call for global solidarity, WHO, 2006 Laura Naismith, Peter Lonsdale, Literature Review in mobile technologies and learning, Report 11, Nesta Futurelab Series Nigel Scot, Simon Batchelor, Jonathan Ridley, Britt Jorgensen, The Impact of mobile phones in Africa, Commission for Africa, 2004 Chetan Sharma, Mobile services evolution 2008 2018, United Nations Foundation Julie Solo, Expanding Contraceptive Choice to the Underserved Through Delivery of Mobile Outreach Services a handbook for program planners, USAID, 2009

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10. References

http://www.cell-life.org/content/blogcategory/13/135/ Visited July 12, 2010, 11:40am http://www.simpill.com/Visited July 12, 2010, 11:30am http://www.voxiva.net/rwanda.aspVisited July 12, 2010, 12:00pm RapidSMS: A Review http://www.mobileactive.com Last accessed July 28, 2010, 10:00am Journal of Information Technology Impact,Vol. 3, No. 2, pp. 69-76, 2003 Information and Communication Technology in Nigeria,The Helath Sector Experience Obafemi Awolwo University, Nigeria Mechael, Patricia N., Exploring Health-Related Uses of Mobile Phones: An Egyptian Case Study, 2006 Rafael Anta, Shireen El-Wahab, and Antonino Giuffrida, Mobile Health: The potential of mobile telephony to bring health care to the majority, Inter-American Development Bank, Innovation Note, February 2009 Globalization and Health 2006, 2:9. Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries? http://www.globalizationandhealth.com/content/2/1/9 Last accessed 12 January 2010, 12.00pm Medical Journal of Australia,Vol 183, No. 7, 2005. Use of SMS text messaging to improve outpatient attendance SundararamanT. Community health-workers: scaling up programmes, Lancet 2007, 369 Ministry of Health and Population, Malawi (2004), Treatment of AIDS, the two year plan to scale up antiretroviral therapy in Malawi UNAIDS (2006), 'UNAIDS 2006 Report on the global AIDS epidemic', Annex 2: HIV/AIDS estimates and data, 2005

Mobile Technology the sixth sense: Challenge? How do we integrate mobile technology Towards Improving Lives of Malawian People?

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