The document discusses a project to improve healthcare access in rural Nicaraguan communities through low-cost telecommunications. Community health workers are equipped with cell phones and diagnostic tools to consult remotely with doctors. Challenges include the human factors of educating and training minimally trained health workers, technical issues of unreliable infrastructure, and ensuring economic sustainability. The project has provided equipment and training to 25 health workers so far and plans to expand, improve software, and measure health outcomes of the pilot program.

1. 1
Making Healthcare More Accessible to Rural
Communities In Waslala, Nicaragua Using Low Cost
Telecommunications
P. Singh, E. Keech, B. Mariani, R. McDermott-Levy and J. Klingler
Villanova University, Villanova, PA
Open 2012 – NCIIA Annual Conference
March 22-24, 2012
San Francisco, CA

2. Outline

Context: health, social and economic parameters

Dimensions of challenge
– Human, medical
– Technical
– Economic sustainability

Progress-to-date

Partners

Future Plans
2

3. General Challenges
• Poor Infrastructure
• Low level of education
• Residue of civil war still influences region
• Generally low income communities
• Language and culture
3

4. Project Context
• Initial pilot location: Waslala - region of approx. 50,000
• Central town surrounded by ~90 rural communities
•Rugged terrain
•Neglected by Public Health System
Waslala
4

5. Healthcare in Waslala

Ministry of Health runs regional hospital

Only 6 trained doctors serve Waslala + rural areas

Catholic Parish organizes and trains community
health workers (CHWs) to promote health

CHWs
– serve their own community
– have limited education (as low as grade 2)
– are trained by parish to extend reach of medical services
and health information
– are volunteers
5

6. Main Hospital in Waslala
6

7. Three Dimensions of Challenge
1. Human Factors, Nursing Training
2. Technical Factors
3. Economic Sustainability
7

8. 1st Dimension:
Human factors, Nursing Challenge

Approx. 90 rural communities

1-14 hours of travel from town (when possible)

Community Health Workers (CHWs)
– Primary healthcare contact
– 2-10 grade education
– Lack basic medical equipment
.. thermometers, blood pressure cuffs, stethescopes, etc.
– Need training in
normal physiology, using medical equipment, preventive care,
basic health assessments,basic medication, patient follow-up,
documentation
8

9. Immediate Healthcare Goals

Provide rapid, real-time computer-assisted assessment
assistance

Develop infrastructure to create, store and retrieve
patient records

Equip, educate & train CHWs

Obtain accurate baseline data

Set outcome measures to match national goals
– e.g. prenatal visits with skilled professional 2-3 times before
delivery
– (hospital) deliveries with skilled attendant
9

10. Medical Equipment, Training
10

11. 2nd Dimension: Technical

Need technology to reach out to rural population

Few have access to electricity; no Internet access

Cell phone service widely available, although not
everywhere
11

12. Proposed Solution

Equip CHWs with inexpensive cell phones

Set up organized system for
– Collecting and transmitting patient information
– Storing and organizing
electronic health records
– Health assessments and
remote medical advice
12

13. System-Level Block Diagram
Solar/Battery
Backup Power Remote Monitoring Center
Rural Sites Cellular
Modem Router
SMS
Medical
Server Doctor's computer
Internet
Solar Chargers
Remote Administration (Villanova)
13

14. Backup Power Supply
14

15. 3rd Dimension: Economic Sustainability
Yearly variable costs (per community) Cost per year
Air time (plan of 1,000 text messages) $120
Replacement of medical equipment* $30
Total variable costs: $150
Expected Yearly fixed costs
Costs Doctor’s wages $1,800
Technician’s wages $2,500
Total fixed costs: $4,300
One-time fixed costs** (per community) Costs per year
Phone $30
Solar cell phone charger $50
Shirts and ID badges $20
Total one-time fixed costs: $100
*Medical equipment – donated; Communities are responsible for replacement of
supplies
**Costs incurred at the beginning of system uptake; avg. equipment lifetime is 3 yrs
15

16. Funding Plan

Operational costs
– Community fund overseen by Waslala parish
– Individual household contributions

Community leader collects monthly fee of $2 per
household

Parish treasurer covers phone, medical or wage
expenses from community fund

Parish treasurer will manage funds through parish
bank account
16

17. Progress-to-date

Teams of ECE, Nursing and Business students and faculty
have made six trips to the site thus far

In-country office staff established

Provided 25 CHWs with diagnostic equipment and training

Provided cell phones and solar chargers to 25 health workers

Installed server and backup power system in parish

Simplified Spanish manuals and text training video produced

Several partnerships established

Doctor brought into team

Some business model concepts established
17

18. Unplanned Challenges
• Personnel Changes
• Spam messages from Claro
• Turmoil at the Parish
• Closing of Internet café in Waslala
18

19. Future Plans

Continue to train and equip more CHWs

Put program into the “Cloud”

Add diagnostics and decision features to software

Maintain emphasis on ultra low-cost

Release software under open-source license

Measure outcomes of pilot project
-Identify baseline assessment measures

Continue to work with communities to develop
and implement a sustainable business model
(including exploring mPeso) 19

20. Partners
Established Partners:
• NCIIA
• Connelly Foundation (supports Nursing travel)
• Halloran Philanthropies
• Parish Health Program in Waslala
• Claro
• UNI (National Engineering School of Nicaragua)
• UNAN (Nursing School in Nicaragua)
• Suni Solar
Emerging Partners:
• MINSA (Ministry of Health in Nicaragua)
• Pro Mujer
• Nicasalud (?)
• Inter-American Development Bank (?) 20

21. Acknowledgments
Electrical & Computer Engineering Students
Craig Baumer, Arpita Kothari, Brendan McCoy, Andrew Robinson, Peter Shaw, John Beyer
Nursing Students
Rebecca LaMarca, Fruna Lara, Caitlin Krenek, Katie Weatherbie, Alexandra Reo, present senior nursing
students, Tracey Desjadon
Business Students
Derek Ferguson, Christina Radossi, Tyler Weinrich, Tara McHugh, Alejandro Avellana
Arts and Science Student
Carolina Wolnicki
UNI Faculty and Students
Maria Virginia Moncada and Carlos Ruiz
UNAN Faculty and Students
Miguel Estapinon and Yolanda, and others
National Collegiate Inventors and Innovators Alliance (NCIIA)
Sustainable Vision Grant Funding
Halloran Philanthropies
Claro
21
Tim Hansell

22. Thank you!
22

23. Backup Slides
23

24. 1st Dimension:
Human factors, Nursing Challenge
Identifying Measurable Outcomes
Nicaragua Profile, WHO (2002) PAHO 2007
24

25. 1st Dimension (outcomes contd.)
Inacurate statistics
Ministry of Health figures
estimated to be 40 – 50%
underreported (PAHO 2007)
25

26. Lessons Learned

Human Factors to Consider
– CHWs prefer to remain unpaid volunteers
– Teaching first time cell users to SMS is really hard!
– Frequent communication with CHWs avoids frustration
– Keep realistic expectations about project progress
– Motivated in-country project co-ordinators are
indispensable
26

27. Lessons Learned

Technical and Logistics Problems
– Even in major towns, electricity, and Internet
connections are unreliable
– Publicly routable IP addresses are the exception, not the
norm!
– Even thorough testing using parallel setups does not
ensure easy success
– Shopping for simple hardware on-site can take several
days!
– Local supplier relationships are essential
27

28. Lessons Learned

Business Hurdles
– Banking infrastructure cannot be taken for granted
– Money moves in mysterious ways
– Credit systems are localized and peer-pressure based
– Custodian of funds is essential
– Entrepreneurial mindset may be lacking
28