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Innovative Mobile Technologies improving health in developing countries
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Innovative Mobile Technologies improving health in developing countries


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  • Bilde av noen kjipe telefoner.Bilde av dårlig strøm/vei…Bilde fra Malawi?Nigeria-story?
  • Kenya: Big push towards a national integrated HIS, funded by USAID. DHIS 2 is used as the national data warehouse, set up as an 100% online system making use of the nation-wide coverage of mobile Internet .Uganda: DHIS 2 used in SMGL pilot districts to capture aggregate data on antenatal care, deliveries and deaths, postnatal care and immunisation. DHIS 2 in the national standard for HIS and is being rolled out to all districts this year.Plan to expand the implementation to include tracking of women and children to reduce losses to follow up and improve the continuum of care.SURE (USAID project) -  Securing Ugandans’ Right to Essential Medicines is implementing an online ARV ordering form using DHIS 2. Used by health facilities to manage consumption and order new drugs and by drug suppliers to keep track of demand and distribution of ARVs. 
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    • 1. Innovative Mobile Technologies improving health in developing countries Professor Kristin Braa Department of Informatics University of Oslo
    • 2. 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
    • 3. 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 PCs in Developing Countries as of 2011
    • 4. Case: India Mobiles 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 Group Internet & 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)
    • 5. • 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
    • 6. 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
    • 7. DHIS 2 as an online national HIS - integrated repository for all health statistics
    • 8. 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
    • 9. DHIS 2 Academy: Regional training program in East Africa, West Africa, Asia, Latin-America Advanced DHIS 2 Academy, Entebbe, 4-13 June 2013
    • 10. = National HIS deployment = National start-up / pilot = early national initiative or program-specific deployment ECOWAS Regional Deployment EAC Regional Deployment Present in over 30 countries, 10 Indian states National standard in Kenya, Ghana, Uganda, Rwanda, Liberia, Nigeria, Sierra Leone, Gambia, Zanzibar, Malawi, Zimbawe
    • 11. JavaSMS Android PC/laptop/tabletBrowser Community / Villages Community Health Workers Clinics Districts / Hospitals Extending the DHIS reach through mobiles
    • 12. A suit of mobile applications for different 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
    • 13. 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
    • 14. 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) 74.7 81.3 79.0 80.7 89.5 94.4 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 Chake Chake District Michew eni District Mkoani District Wete District Central District North A District North B District South District Urban District West District Pemba Zone Unguja Zone District Annualmeaslescoverage% Data from Mobile devises -Data mart -Meta data -Visualising tools Dashboard Graphs Maps Getting data in - Data warehousing Getting data out - Decision support systems Web Portal Mobile
    • 15. • 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
    • 16. 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 based services Mobile broadband Web- based Country wide implementation
    • 17. Offline support Server Unstable network • Network coverage variability/instability requires offline capabilities • When there is no coverage – store locally and submit later
    • 18. 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.
    • 19. National HIS Database Uganda ”Saving Mothers Giving Life” 27.09.2013 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
    • 20. Weekly reporting Dashboard Graphs MapsMobile Send to 6767
    • 21. Results
    • 22. Results
    • 23. 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
    • 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 project27.09.2013 24
    • 25. Find Person, Enroll and Add Relationship
    • 26. DHIS on smartphones with offline support
    • 27. Leverage on the social network
    • 28. 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
    • 29. 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
    • 30. Research agenda: Pilot to scale Pilots Early decisions of solution type create path dependencies
    • 31. 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!!
    • 32. Rwanda South Africa Malawi Tanzania Burkina Faso India Norway HISP collaborative Network of Action Health Information Systems Research, Implementation Development Open Source Software DHIS2 Sharing across the world Capacity Building Training, Education, Research Botswana Vietnam Togo others Nigeria Liberia Ghana Sierra Leone Gambia Côte d’IvoirSri Lanka Mali Bangladesh Uganda Partner contribution PSI, Pepfar, Global Fund Use of DHIS for own reporting & development Regional development West Africa & East Africa: Kenya
    • 33. High tech – low resource – big impact
    • 34. Thank you
    • 35. Thank you
    • 36. • High tech – low resource – big impact •
    • 37. Hich tech – low resources - big impact Lightweight Browser SMS Android app or browser Tablet PC/laptop
    • 38. 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
    • 39. 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
    • 40. 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
    • 41. 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!
    • 42. 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).
    • 43. 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.
    • 44. 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
    • 45. Expanding the DHIS 2 reach through Mobile technology A suit of mobile applications for different 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
    • 46. Using DHIS2 Mobile SMS client for real-time reporting from the community SMGL Village Health Team Weekly reporting in the 4 SMGL pilot districts