Archive for E and M Health

Summer School 2016 – Uganda

I am currently a Year 2 student in the MSc Global eHealth course from the University of Edinburgh. eHealth is an emerging field at the intersection of medical informatics, public health and business, referring to health services and information delivered or enhanced through internet and related technologies. Each year The University of Edinburgh runs a Summer School Programme which draws together cohorts of Masters level students studying across the domain of One Health and Global Health: Innovation and Education. I was eligible for the programme and jumped on the occasion to meet friends which I encountered virtually only. This year’s Summer school took place in Uganda at Makerere University in July.

Uganda was a pleasant surprise for me. I reached the airport and happy to have good WIFI to talk to my family. The roads are loaded with vehicles and Ugandans are hard workers. They never seem to sleep. I was told that every day nearly 2 million people move to and from Kampala for work. Whoa! Mauritius where I am from is only 1.3 million people. Uganda has a population of 39 million with GDP growth of 5% (Source: Wikipedia). This is pretty impressive and promising African country.

The Summer School programme kicked off with a discussion on One Health and Sustainable Development Goals (SDGs). It was great to see the lecturers in action. We have been discussing a lot on the discussion boards and it was clear that we are not strangers but friends on a mission for better good. There were workshops on presentation skills and I got the opportunity to pitch my work and receive valuable feedback. The sessions on epidemiology have been made simple and I could grab the concepts better. Day 1 was pretty heavy but I seemed to get a better grip of the structure of the programme as the days went by.

The great thing about Online distance learning is that all the students are busy working professionals in their own fields. This programme provided a platform to network and talk about potential synergies. Each one of us is contributing in our fields and learning the best practices from different areas is pivotal to acquire the multi-disciplinary skills of future leaders.

We had a comprehensive data analysis workshop with Professor Michael Thrusfield. It was the first time I truly understood the meaning of p value and t-test. The workshops ended daily with inspirational talks from alumni and students.

Professor Michael Thrusfield

Team building workshops were interesting and allowed us to know our friends better. From writing press releases to data analysis on quantitative studies, a wide variety of activities fostered a challenging yet fun environment to learn.

I finally managed to meet Dr. Liz Grant. She signed my scholarship letter in 2014 and I am indebted for the support she has given me since then. This MSc has challenged me to step to the next level and move ahead in my career.

Amal Bholah and Liz Grant

 

 

 

 

 

 

 

The final day of the workshops, the students gathered up and went for dinner. We had 1.1 million Ugandan Shillings worth of food and it was really tasty (1 GBP = 4451 Ugandan Shillings).

dinner receipt

The University of Edinburgh organized a trip to the forest of Budongo were research is conducted to understand the relationship between biodiversity, forest management practices. We stayed in a lodge which was far better than I expected. We spent two nights there and I was impressed by the hospitality of Ugandans. On day 2 we went chimpanzee tracking. We walked nearly 3 hours in the deep forest of Budongo appreciating the wildlife. It was surprising to see how the chimpanzees were undisturbed by humans. I saw a really balanced wildlife ecosystem. Our guide could identify the chimpanzees from far and even called them by name. Wow. These guys are doing an amazing job to preserve wildlife and also maintain a peaceful balance between humans and wildlife. I enjoyed these two days in Budongo and it’s recommended to all those visiting Uganda.

Budongo

The key aspect of the Summer School Programme is that I made great friends from different fields who are leaders of tomorrow.


 

Dr Leckraj Amal Bholah, MSc Global eHealth, University of Edinburgh

Dr Leckraj Amal Bholah

 

 

 

 

 

Preferential Software for the Poor

Millions of families who have never accessed the Internet, used landline telephones or even postal service have now begun using mobile phones. Increasingly governments, charities and tech companies see this new infrastructure as an opportunity to re-imagine the way that we deliver health care. While this field is young and riddled with disappointments, some mobile health, or mHealth initiatives have yielded impressive results. For example, inexpensive text messaging programs have improved quality of care for children with Malaria (study), increased adherence to HIV medication (study), and made community-based support as much as 137 times faster and four times less costly (study).

I wish that I could say such studies prove that communication technologies boost health outcomes, but sadly I cannot. Perhaps this field’s most inconvenient truth, observed again and again by practitioners and scholars, is that technologies that are effective in one setting often have very different effects in other settings. It is not difficult to see what makes mHealth so complex; the daily routines by which people make use of technology as well as the technologies themselves are diverse and continually changing. It is more difficult to determine how we might cope with unpredictability and make the most of mHealth opportunities. Currently popular prescriptions include selecting technology that is scalable, fostering collaboration and planning for financial sustainability from day one.

I would like to suggest that we begin by listening to the poor and marginalized individuals who stand to benefit from our work. Listening is a matter of such practical importance that I often think of it as the core competency of the team at Medic Mobile, the mHealth social enterprise I co-founded. We begin by making time for long conversations with people from each of the groups any new initiative might touch. No project moves forward until we have listened long enough to begin seeing the central strengths and constraints of each group from their point of view. Hearing of their daily concerns goes hand in hand with imagining alternative futures, and we always draw sketches of how our collaboration might change their community. By ‘we’ in this case I am also referring to the beneficiaries because sketching and brainstorming is collaborative wherever possible. When we sketch what a future service might look like, we consistently receive more detailed and often more critical feedback than through conversation alone. Making it easier for people all over the world to give feedback on our intentions forces us to listen not only more patiently but also more pragmatically. The number of times we have thrown away old sketches and drawn new ones, always based on feedback, is a reasonable gauge of how well we have listened.

Listening meaningfully is also a great intellectual challenge because appreciating the circumstances of any poor person involves understanding global poverty. The first time that a community health worker in Malawi told me that he had to walk 15 kilometers and spend a third of what he would earn in a typical day just to charge his phone, I understood that an mHealth initiative designed for him would need to reimburse for electricity and use phones which hold a charge for a week or two. Having now heard similar stories from dozens of health workers, it frustrates me how the mHealth community obsesses with fancy smartphones that need to be charged everyday. I have had similar conversations with facility-based staff who lament that the internet is slow, unreliable or absent from their clinics. These are the clinics most in need of support, and yet nothing is more in fashion than to boast that one’s mHealth application is “cloud-based.” International development agencies often write requests for proposals that explicitly call for cloud-based apps because they are deemed ‘more scalable,’ which in turn pressures charities that rely on such grants to write cloud-biased proposals. After many cycles of such investment, it should not surprise us that cloud and smartphone apps are among the most ‘tried and true’ tools in the global mHealth community. Neither should it surprise us that when the ‘best tools’ excel in more urban and middle-income environments, the tools themselves come to incentivize organizations to focus not on the poorest, but on middle-of-the-road needy communities where the tools are likely to be relevant.

To be sure, smart phones and cloud servers can be tremendously helpful in many settings. It seems almost counter-intuitive to suggest that we could ever go wrong by maximizing ‘value for money’ with technologies that are ‘cost-effective’ enough to ‘go to scale’ nation-wide. No one seems to be intentionally marginalizing the poorest. An alternative view may only emerge when we not only listen to the poor, but spend enough time in their company to appreciate that they are subject to a perpetual train of abuses and unfair disadvantages. The most difficult to perceive are the abuses which are nobody’s fault, the suffering which seems inevitable because it flows not from evil people but from patterns of society that have long been taken for granted. Some use the term ‘structural violence‘ to describe such social arrangements that tend to put specific groups in harm’s way. Revisiting this concept has helped me attend to who gets left behind when we design technologies with a utilitarian focus on the characteristics of the average needy community. Many who call attention to structural violence have also argued that the only means of addressing such systemic unfairness is to build a preferential option for the poor. What would preferential software for the poor look like? Perhaps I can explain this most clearly with an example.

My first mHealth project was with a rural Catholic hospital in Malawi called St Gabriel’s. We gave phones to about one hundred community health workers so that they could exchange logistical information such as “Mary Banda in Msangwa village might have Tuberculosis and I want you to come test them.” The project was successful enough that many other organizations asked us to replicate it, but they wanted to use more quantitative data in more complex ways than our initial approach to simple prose text messaging. At the time, industry experts referred to durable, inexpensive and long-battery-life phones as “dumb” or “SMS-only” phones because they “couldn’t run apps” that would support forms-based data collection or menu-based decision support. Bucking conventional wisdom, I fixated on the idea of putting apps on $20 phones because it seemed the only way to move beyond the limitations of text messaging without leaving behind communities like St Gabriel’s.

During a trip to Kenya I learned of the popular mPesa mobile banking service. It involved simple menus and worked on the cheapest phones–it was possible! How ironic that the experts in my field had neglected to discuss a technology that 70% of adults in Kenya were using. I learned that mPesa was installed not on the phone itself but on the SIM card, so I began talking to mobile network operators about putting health apps on their SIM cards. I was told again and again that it simply would not be possible unless I were prepared to pre-order a custom batch of 10-50 thousand SIM cards (and my funders said that would be impossible). More than a year later I discovered a small Eastern European manufacturer of paper-thin ‘parallel-SIM’ cards that slide underneath a typical SIM card. Using this technology, we could install our apps on the parallel SIM and keep using ordinary SIMs to connect to the mobile network. Medic Mobile soon began developing a parallel SIM card app called Muvuku, which means ‘to listen’ in Chichewa, one of the indigenous languages of Malawi. Since then we have used it in more than a dozen countries and it has won a few awards. Conveniently, it also works well for programs that could afford more expensive phones and that do have access to electricity and local smartphone suppliers. It was harder and took much longer to develop than an Android app though. It was only worth the effort because of a commitment that has more to do with who we are than it has to do with maximizing impact or going to scale. While we’re open to working in any setting that would benefit from our support, we design our core technologies in partnership with, and to suit the circumstances of poor and marginalized communities.

What does it mean to make preferential software for the poor? I do not mean to argue that the solution lies with any one technology or in dealing with any particular constraint, be it electricity, usability, adaptability or local availability and appropriateness. Rather, it means standing with the poor, spending time in their company and appreciating their strengths and constraints—as they see them—before attending to technical or financial concerns. I believe this matters because engineers and economists too often advocate for their expertise in ways that make the aspirations of the poor seem impossible, or even a waste of resources. In recent decades we have heard that HIV prevention is ‘cost effective’ but treatment is not and that patients who do not respond to the cheaper classes of Tuberculosis drugs are ‘untreatable.’ Today many still argue that poor community health workers can volunteer while their bosses receive comfortable salaries and that the ‘dumb phones’ which have proliferated all across the African continent are not ‘smart’ enough to extend the highest standard of medical care. These social fictions stem from a poverty of imagination about what is possible. They stem from a traditional deference to the expertise of foreign technical elites over the lived experience of beneficiaries. To be sure, spending time in the company of the poor will not render all problems easily solvable. But listening patiently and with a deep sense of humility is a decent place to start.

 

Isaac Holeman, Medic Mobile 

Isaac Holeman is a designer and a scholar striving for global health equity. Through ethnography and innovation, his work is about seeing through the eyes of the poor and marginalized and responding pragmatically. He has pursued this work as a cofounder of the mHealth social enterprise Medic Mobile, as an Echoing Green Fellow and as a Gates Cambridge Scholar.

Maternal and infant health in Malawi

For the last 15 years women in rural Malawi have been experiencing high rates of maternal and new-born illness and death due to preventable complications of childbirth. Three main factors precede the majority of poor maternal and new-born health outcomes: firstly a delay in making the decision to seek care, secondly a delay in getting to an appropriate health facility, and thirdly a delay in receiving appropriate care within the health facility.

Context of ICT implementation at Diamphwe and Mtenthela health centres 

The absence of patient data for decision-making at health facility level remains one of the greatest weaknesses of the Malawian health, which is characterised by antiquated, paper-based systems and a reliance on mothers to hold their own paper-based records, known as ‘health passports’, as well as that of their infants. Implementing electronic health information systems (eHIS) across hospital and community care has potential to reduce birth complications by ensuring that the right information about the right patient is available to the right people at the right time and place. Enabling information to flow between community-based and hospital-based care settings may enable more informed decision-making about high risk cases in need of referral for specialist management, leading to improved maternal and new-born health outcomes. Since 2009, there has been significantly increased commitments to and investments in the strengthening of eHIS at Nkhoma Hospital in Malawi. This is being done through integration of information and communication technology (ICT) in the running programmes of at Nkhoma Hospital and it’s surrounding health centres to increase the quality and effectiveness of development interventions. The ICT solution being implemented is AfyaPro, which has seven (7) modules: patient registration, patient billing, diagnosis and treatment, medical laboratory, reproductive and child health, inventory, and HIV-ART. Beyond installing AfyaPro, efforts have been to strengthen eHIS through a change management process aimed at facilitating ICT ownership, increasing ICT competencies and assisting with institutional integration of ICT at the health facilities. The first stage of implementation involves replacing the paper registers that are currently used in antenatal and delivery care with electronic data capture using AfyaPro. The electronic data is linked to the health passport through a bar code system, as well as being retrievable through name, year of birth and village. Electronic patient data are stored securely in a local and central database and accessible at the referral hospital and the other health centres. In the continuum of care, if a woman is referred from her primary health centre to the referral hospital, or transfers to another health centre, her file is directly available at the referral site, improving quality of patient care.

So far, computers and other hardware have been installed at Nkhoma Hospital and health centres. Health workers have been trained in the use of computers, Afya Pro applications, as well as change management. There is now need to study how the electronic health information system impacts quality of care and health facility management, and ultimately maternal and new-born health outcomes.

 

Nkhoma Safe Motherhood Scale Up Programme

The main aim of the Nkhoma Safe Motherhood Scale Up Program is to increase family planning and referrals, and the utilization, timeliness, and quality of reproductive health services, while building partnerships and advocating for reproductive health and rights to reduce maternal and new-born deaths in the Nathenje Health Area. Nathenje Health Area’s main referral hospital, Nkhoma Hospital, is surrounded by five health centres: Matapila, Nathenje, Chimbalanga, Diamphwe and Mtenthela and they all work together in this program. The Nkhoma Safe Motherhood Scale Up program covers Traditional Authority (TA) Mazengera in 22 group village heads. To achieve its goal the program uses many activities that have been clustered under the following strategies to address the three delays (delay in seeking health care, delay in accessing health care, and delay in service provision):

 

Strategies to increase in family planning methods and referrals

  1. Strengthening community structures to act on modern family planning
  2. Women empowerment
  3. Youth empowerment/Mobilization
  4. Strengthening community structures to take family planning to communities
  5. Strengthening quality assurance in the health facilities

Strategies to increase referrals

  1. Empowering the community to organize transport for referrals
  2. Strengthening communication systems
  3. Strengthening quality assurance in the health facilities

Strategies to increase women using health care facilities for skilled delivery and reproductive health care on time

  1. Strengthening community structures to act MCH/MNH/SRHR issues
  2. Women empowerment
  3. Maternal death audits

Strategies to improve quality and quantity of reproductive health services

  1. Improving skills and attitude of health providers
  2. Ensuring adequate resources to conduct sexual and reproductive health
  3. Improving availability of information

Strategies to build partnerships and advocate for SRHR issues

  1. Advocating to church leaders on SRHR issues
  2. Lobbying for SRH issues (patients rights, human resources and infrastructure)
  3. Developing networks with local/national government and NGOs
  4. Mobilizing and distributing information, education and communication materials

Church leaders have been invited to various meetings and have been trained in issues relating to SRHR. There is need to follow up on the advocacy with the church leaders to identify specific actions taken. The project provides a leading role in a local and national network, called Uchembere Network.

There is an exchange programme established for health providers, so they can experience work in the maternity ward of the hospital or another health centre. There is need to further develop this strategy to improve skills and attitudes of the health providers.

Each facility maternal death is audited, yet community-based maternal deaths are rarely reported. There is need to develop a mechanism for capturing all community-based maternal deaths, and subsequently conduct an audit.

A community bicycle ambulance system has been developed and use of bicycle ambulances are being monitored by the community and the project. A wireless communication system set up among the health centres and Nkhoma Hospital is being maintained. There is need to further develop the voice over internet protocol communication system to be able to share document, picture and video among the health facilities. There is also need to evaluate the sustainability and cost-effectiveness of the bicycle ambulance system.

Community structures such as Area Development Committees in the Traditional Areas have been strengthened. Women’s groups in the 22 villages have been set up to empower women. Training of youth from churches in the catchment villages has mobilized them. Community based distribution agents have been trained and are being supported to take family planning methods closer to people’s homes. A quality assurance system ensures a team from Nkhoma Hospital supervises the health centres, and staff from the health centres learn from each other. There is need to evaluate these strategies increase access to family planning methods.

 

 Paul Kawale 

(Director Community Health,  Nkhoma Hospital, Malawi and PhD Student, University of Edinburgh)

https://www.facebook.com/pages/Nkhoma-Hospital/263372044008

http://www.linkedin.com/pub/paul-kawale/30/787/66

mHealth and User Centered Design in low resource settings

Walk into almost any corner store in India, Pakistan, Zambia, Mexico, or Tanzania and you will find cell-phone top-up cards for sale. Corner stores and markets and even street vendors understand that mobile phones mean business. There are now more than six billion wireless subscribers in the world, and more than 70% of them reside in low- and middle-income countries. The Global System for Mobile Communications Association (GSMA) reports commercial wireless signals cover more than 85% of the world’s population, extending far beyond the reach of the electrical grid.

As global health NGOs join governments, health care, and donors begin to build the foundations for a cancer control strategy in places such as sub-Saharan Africa, we need to incorporate mobile health strategies and monitoring mechanisms to unleash the potential of those six billion mobile users to further awareness, advocacy, and behavior change goals.

A 2011 WHO report on mHealth states: “The use of mobile and wireless technologies to support the achievement of health objectives (mHealth) has the potential to transform the face of health service delivery across the globe. A powerful combination of factors is driving this change. These include rapid advances in mobile technologies and applications, a rise in new opportunities for the integration of mobile health into existing eHealth services, and the continued growth in coverage of mobile cellular networks.” If we intend to
improve access to cancer control strategies known to be effective such as HPV and Hepatitis B vaccines, and cervical cancer screening, into our global mission to fight cancer in low and middle income countries then the use of mHealth will certainly form part of the tools to accomplish those goals.

Most patients in sub-Saharan Africa walk away from the clinic visit with a cell phone in hand, but lack access to resources about treatment, work-related issues, and transportation to receive the treatments. If they are fortunate enough to have access to treatment, they may have no way to communicate problems or questions as health facilities could be miles away by foot from where they live. Mobile technologies could help bridge the gap for patient support services. As a global health community, we should support adequate resources for more research and development of effective mobile strategies to urgently address cancer and other other non communicable diseases, the cause of 63% of global deaths.

There are few global foundations underwriting programs to support the understanding and development of mHealth in cancer interventions. If foundations, governments and private individuals were made aware of the
potential impact that mobile based Cancer applications could have on their dollars already invested in health services there is little doubt that they would get behind the deployment of such technology.

Medic Mobile is partnering with the University of Edinburgh on the creation of a series of courses focused on mHealth and User Centered Design in low resource settings.

 

Jay Evans, Regional Director , Asia for Medic Mobile
Jay Evans TH

 

 

 

 

Twitter: @jaymedicmobile

 

The potential impact of technology on health delivery: NCDs

 

The number of mobile subscriptions in use worldwide, both pre-paid and post-paid, has grown from fewer than 1 billion in 2000 to over 6 billion in 2012 (current world population estimates are near 7 billion)” (1)

Facebook has reached more than 1 billion active users and every minute, 48 hours worth of content is uploaded to YouTube  (2)

During this last decade we have had to make two fundamental shifts in our thinking about NCDs:-

Firstly that NCDs are also a major health challenge in low and middle income countries – gone are the days when NCDs were seen as the disease of rich countries and infectious diseases as the disease of poor countries.

Secondly that NCDs only affected the middling to older aged population.   NCDs affect everyone and transforming the NCD world picture demands a life course approach to policies and interventions if the burden is to be reduced in any significant way.

A new report from NCD Child entitled “Young people and NCDs: Harnessing the culture of technology”(2) highlights the link between the exponential rise of mobile phones, the use of technologies  and a younger generation more tech-savvy than any generation that has gone before, and argues that   “A life-course approach to prevention (primary, secondaryand tertiary) that pays greater attention to adolescence and acknowledges major cultural drivers of change in young people’s attitudes and actions is central to mitigating the effects of NCDs in individuals, communities and societies now and in the future.”  Harnessing this in the battle with NCDs is a priority.  We desperately need new ideas, new plans and new tested and trialled interventions to improve young peoples’ health through mobile technology.

” We need to communicate what NCDs are, and why they matter to a global audience of young people – the generation who must solve this issue ” Dr Alessandro Demaio, NCDFREE

A white paper produced by mHealth Alliance in 2010 (3) highlighted some of the barriers and gaps to making mHealth widely available, such as security of patient information and policy etc and that “Governments need to develop a strategic eHealth framework in which mHealth is an integral component in order to provide mHealth implementers in the NGO and private for profit sectors more guidance when implementing projects to ensure alignment with their eGovernment, health information systems, and other relevant policies and aims to leverage technology for public good(3).

This latest report (1)  highlights not only the availability of mobile phones worldwide and shows that this is continually increasing, but also looks at the some of the key barriers to full implementation – patient privacy and security of patient information.  Mobile technology has the ability to help greatly in the drive for health equality and we need to capitalise on this – however we also need to ensure that the barriers are addressed for maximum worldwide benefit.    There has been some success to date and harnessing the young and tech-savvy in the battle with NCDs is another excellent step which is easily transferable to other disease areas.  However the question now is how else do we continue to maximise this particular technology as an added value in health delivery globally, ensuring that barriers are cleared, gaps are filled and it becomes an integral part of health policy and delivery?

 

Dr Liz Grant, is Deputy Director of the Global Health Academy at Edinburgh University

mgrant1  photo

 

 

 

 

References

(1)      Patient privacy in a mobile world a framework to address privacy law issues in mobile health

http://www.mhealthalliance.org/images/content/trustlaw_connect_report.pdf

 

(2)     NCD Child – Young people and NCDs: Harnessing the culture of technology

https://www.dropbox.com/s/ylubv2umqbzn8kx/2013%20Issues%20Paper_FINAL%2024%20June%202013.pdf

 

(3)     Barriers and Gaps Affecting mHealth in Low and Middle Income Countries: Policy White Paper.

http://cghed.ei.columbia.edu/sitefiles/file/mHealthBarriersWhitePaperFINAL.pdf