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Device X in Uganda


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Device X in Uganda

  1. 1. Benedetta Piantella 22-53 24th Street Astoria, NY 11105 US +1 347 495 1237 UG +256 784 285876 Preliminary Research on Device X in Uganda In December 2009, I traveled to Kampala, Uganda, from December 8th through December 20th 2009, with the intent of establishing the validity of employing Device X or an analogous networked data-logging device via in field research, in clinics throughout the region. This preliminary research focused on ways to gather accurate, high volume data rapidly from the field, especially in areas where it is not feasible to do so efficiently at this time, because of distances, lack of network coverage, lack of electricity and the highly hazardous delays involved in physically processing and transporting paper data. In those twelve days, I conducted extensive research in the medical arena and began to establish contacts and expand possible applications for Device X in the fields of education, emergency relief and aid distribution. Through observation and interviews conducted with community health care workers, representatives of different departments within the UNICEF Uganda Country office, representatives of Government institutions, members of other not-for-profit organizations and NGOs active on the Ugandan territory, I compiled a list of important findings that constitute the basis for the suggested next steps in the development of this device. Based on these findings, further research on current data collection processes is necessary to target the future technical implementations of Device X. Also, continuing the communications with local suppliers, training institutions and manufacturing facilities will be vital to establish the long-term production method and sustainability of this project. The new and improved prototypes will undergo extensive in field technical testing as well as user testing in Uganda. The information and user feedback collected during this research period will lead towards a final hardware/software architecture to troubleshoot and solve the many challenges associated with collecting accurate data from the field. Visits and initial impressions 1. Research 2. Findings 3. Sustainability 4. Other Applications 1. RESEARCH: Preliminary research and assessment of Device X in the context of Government Health Clinics in Uganda. In order to design an efficient, rugged and easy to use data-logger, we started by focusing on one specific and useful application for such a device: the collection and transmission of medical data in government health clinics in and around Kampala, Uganda. The clinics explored were: the Mulago Hospital (Level V, the largest hospital in Uganda), the Kasangati Health Center (Level IV/III) and the Kiruddu Health Center (Level III/II). I had the pleasure of working with John Baptist Niwagaba, a Doctor who has lived and worked in Kampala and is extremely familiar with both the health care system and mobile technologies in Uganda. He provided invaluable feedback during this preliminary research process. Flavia Mpanga and Francine Kimanuka, of the UNICEF Uganda Country Office, were incredibly helpful in providing Ministerial forms as well as specific suggestions on what clinics to visit and research. Mulago Hospital is a Level V Health Clinic. There, I was introduced to the Depute Director of the facility who, after reading my presentation letter and listening to my explanation, requested a demo of the device. He complimented us and gave me written permission to explore the building starting from the 

  2. 2. Pediatrics department. Unfortunately the Director of the Pediatrics department didn’t allow me to do any observation of their process and instead requested that I present a full proposal on the purpose of my research, so unfortunately no useful data was obtained. Kasangati Health Center is a clinic Level IV acting more as a clinic Level III, since there was no doctor on staff but only a Clinic Officer and two nurses. This is a very common situation in most health clinics in Uganda. I received a full tour of the facilities from the Clinic Officer who showed me every process and every document involved in the clinic’s daily tasks. The clinic presented a physical structure with open windows, open doors and allowed for large amounts of dust to penetrate the building. The structure offered: a child clinic for immunizations and early stage of life check-ups, a small inpatient section, a maternity section and a busy outpatient area. The child section visits 15-30 children on average daily, 140 children monthly for immunizations. The clinic opens at 8am and closes in the early afternoon around 3pm. There were more than 100 patients in the outpatient section, which does not close until the patients have all been visited. Electricity and a reservoir of water were available as well as two PC desktop computers, a printer and a copier in the clinic office. I came to learn that The Rotary Club had recently donated five more computers to the clinic, but nobody yet had the technical skills to link them together in a local network and, therefore, they were not being used. The clinic had cell phone reception in some areas but not all (MTN between -61 and -81dBM). Kiruddu Health Center is a clinic Level III also acting like a clinic Level II. I was introduced to one of the nurses on staff and taken around by the officer in charge of registering patients, Eddie. I toured most departments and buildings within the clinic and interacted with each officer in charge. The clinic presented a physical structure divided in different sections and buildings, which included a children section for immunizations, an ARVs children dispensary, a maternity section, an overwhelmed outpatient section, multiple medicine dispensaries (one solely dedicated to adult ARVs distribution) and an HIV testing laboratory. The structure presented power available and in use. On average, the outpatient section of the health clinic visits 170 patients daily but it often receives and diagnoses more than 200 patients, between children and adults. The clinic area offered network coverage in some areas but not all (MTN between -75 and -85dBM). This clinic is part of the Infectious Diseases Institute (IDI) of Makerere University KCC Capacity Building Program, created
to strengthen the care and management capacity of KCC clinics to deliver comprehensive HIV prevention, care and treatment services. 2. FINDINGS: User findings and changes necessary for the creation and testing of future prototypes of Device X. In such a brief period of time in Kampala, I managed to collect an impressive amount of feedback and information from health care workers and people involved in bettering the health care system in Uganda. Some of the most important discoveries made, were: Weatherproof casing: Given the nature of the physical structures of the health clinics I visited, and given the mobile nature of Village Health Teams and volunteers, further research on weather-proofing and dust- proofing the device is necessary and it will be important to make the casing of this device more robust and able to withstand all elements. Languages: Given the many languages and dialects spoken in the different districts in Uganda, focusing on the main four languages would be a good place to start. The messages should be therefore translated and recorded in: English, Swahili, Luganda and Runyakitara. Power: In most cases the device needs to operate for a minimum of 7 hours to a maximum of 13 hours daily. For the clinics that offer electricity, a wall charger is a viable recharging choice, while for those with no power, recharging through a photovoltaic system and rechargeable batteries, through car battery or generator seem to be the most practical options. 

  3. 3. Data: It is undeniable that there is an extraordinary amount of paper data involved in all the medical processes that I have observed during my visits in the field. Most of this data is purely text and numerical data which includes patient’s name, province, age, weight, temperature, medical history, conditions, diagnosis, treatment and in some cases laboratory test results. All this data can easily be stored and efficiently processed by Device X. Clinic officers and nurses at Kasangati expressed the concern about the lack of local medical records from as early as 5 years prior, and were alarmed by how frequently the clinic loses valuable information. Device X could certainly constitute a local storage system for these clinics. Process: From hours of observation and from interacting with doctors, nurses, clinic officers and volunteers, it is obvious how repetitive and time consuming the constant manual data logging process is. The process of collecting this high volume data is labor and manpower intensive. Everyone interviewed described some form of complication or issue associated with such time consuming method. The same ‘line’ of information was manually transcribed on at least 2 to 4 daily ministerial registries, on at least 1 monthly tally, as well as on a local hard copy for the clinic to keep and this process gets repeated within every department of the clinic. On top of the amount of physical paper involved, the process of data transcription takes health care workers away from other more valuable tasks and creates long waits. Also, this process requires multiple employees dedicated to manually inputting all the paper data into the computer (wherever possible). At Kiruddu, the clinic had run out of patient registration forms and ministerial registries and had purchased paper logs from a private supplier. At Kasangati, the Government was piloting a new form that most nurses and officers pointed out to be too lengthy yet very limited and not particularly useful. A great deal of medical training and experience is required in properly diagnosing and treating patients, and none of the methods employed in the government clinics that I have visited, were intuitive nor resource efficient enough, instead they were highly prone to human error. Every clinic seemed to employ similar methods and processes for data collection, but also employed a completely individualized local record keeping system. At Kasangati, children in the earlier stages of life were measured against the ministerial Child Health Card and diagnosed with the use of weight/age ratio charts. The same weight/age ratio chart was used at Kiruddu, but the patient information was recorded on a rulebook that the mother had to bring back with her at each visit. Muac measuring was not a standard in most of the clinics I visited. The actual process of registering and assigning the patient id numbers was also very similar in most clinics: children under five years old retain the patient id given at the first visit, while older children and adult patients are assigned new ids monthly. It was apparent to me how much every clinic would benefit from a universal and shared patient id system. Usability: Although user testing was outside of the scope of this preliminary research, I have managed to gather some valuable information from the health care workers I interviewed about the actual form factor of the device itself. I asked all people interviewed if they owned a mobile phone, and the answer for everyone was ‘yes’. I interviewed health care workers that ranged in age from early twenties to late forties. When asked about typing on a cellular phone, the majority of interviewees told me that they only typed short message because of their uneasiness in typing on a cell phone keyboard. Most of the interviewees were, in fact, much more comfortable typing on a computer keyboard, while a small percentage was not comfortable typing at all. In their opinion typing text messages on a cell phone was more appealing to younger crowds. The female health care worker, who registers children at Kasangati, expressed her concern about not retaining a paper copy. This showed that there is some reservation towards new technologies and a lot of attachment to paper format. I think we could work towards a technological solution that connects to a 

  4. 4. printer, or ideally any printer, so that paper copies can be produced anytime. Part of the goal of Device X is to recreate their current process and not disrupt it completely. The same health care worker, was very accustomed to the manual transcription of data after ten years in her position, but she expressed interest in learning any new tool that could contribute to a more efficient local record keeping system for the Kasangati health clinic, because of the many advantages of sharing that information with other clinics and with the Ministry of Health directly. She was very willing to learn, although she does not normally type information and does not like typing on her cell phone. At Kiruddu Health Center, I interviewed two nurses in the HIV child department: Florence Natukunda and Shafic Kayemba, both in their late twenties. They also only typed short messages on their mobile phones, but where much more comfortable typing on a computer keyboard. They comfortably used Device X and thought it was a good tool that could simplify their tasks. They had a preference towards big monitors and big keyboards for better usability, but they overall agreed that a device like Device X would make their processes more efficient and would make the communication with the Ministry, for example about daily dispensing of ARVs, much faster. Florence and Shafic suggested an HIV-specific program for Device X that would cover questions about previous HIV testing, medical history, medications taken and side effects of medications. This program could be easily implemented at this time. They appreciated the size of the device because of its portability especially when used in remote locations. They actually expressed their concern about and asked regarding ways to dispense drugs in far away locations and villages, which poses another very interesting challenge. Generally, the men and women interviewed during this trip, had basic knowledge of computers and mobile phones and most of them would rather type on a computer keyboard or press buttons, rather than write or type on a cellular phone. All the health care workers interviewed were very interested in the translation capabilities of the device, and considered it an incredible asset, because of the many languages and local dialects the patients and their families speak; Device X could bridge those gaps and potentially make all communications effortless. 3. SUSTAINABILITY: Preliminary research on local availability of parts and electronic components. Initial assessment of the feasibility of a sustainable long-term production method of the device, including search for skilled local technicians, local suppliers and training facilities. Electronics suppliers: Kampala Road is a great resource for all kinds of consumer electronics ranging from mobile phones, personal computers to household appliances. One store carried actual electronic components and smaller hardware parts: New Master Electronics LTD on Plot No. 88 Ben Kiwanuka Street. They also had direct communications with particular Indian manufactures and distributors, and therefore could research and order hardware parts, not currently available in the store. The store offered a limited selection but it is still a really valuable resource. I compiled a pricelist of all their available components useful in the local production and assembly of Device X at this time. Anna Spindler, Supply Manager at UNICEF Uganda Country Office, Paddy Wanzala and Enid Murungi were extraordinarily helpful in the search for local suppliers; they made great suggestions on sustainable ways to procure parts and provided local contacts such as a local business that supplies and imports electronics called Cyberbase Limited. I have been in contact with the Marketing Manager, Daniel Lutaaya, about future iterations of the device and whether or not Cyberbase could provide the parts necessary. Training schools: Nakawa Vocational Training Institute, which we visited with Khalid Arbab, ICT Manager at UNICEF Uganda Country Office, had a full curriculum of classes that taught analogue and digital electronics, radio and TV systems, computer systems, soldering and de-soldering practices, electronic repairs and circuit board etching. I asked to see samples of past semester work and it was very exciting to see locally soldered electronic circuits. I think building a relationship with this vocational 

  5. 5. school as well as other training institutes or Universities like Makerere would be a great place to begin the training of local skilled technicians in order to create and alternative economic resource for the growth of the Country. 4. OTHER APPLICATIONS: Preliminary research on other possible applications and implementations of the device. Findings from meeting with partnering organizations, NGOs, health institutions and government representatives. John Baptist Niwagaba, a Doctor born, raised and trained in Uganda, provided lots of incredible feedback about the device itself and its form factor and also suggested to use this device to gather not only medical data, but also any kind of data that is now presently collected in paper form. For example he suggested Device X as a valid alternative to be employed in the upcoming census that the Ministry was currently preparing. Device X could also be reprogrammed and adapted to collect and process information in the field of education, as suggested by Margo O'Sullivan and one of her assistants Humphrey, both of UNICEF Uganda Country Office. It could in fact be used to take students’ and teachers’ attendances, it could record and timestamp class schedules, store the school curriculum, track school supply stock as well as make projections on and therefore prevent stock-outs. It could compute the overall productivity of the school and could be used at the same time as a learning tool and testing platform. Dr. Alex Opio Chono, Health Coordinator for the International Rescue Committee, suggested spending time researching (on a future trip) specifically Village Health Teams in the Karamoja sub-region, and focusing on detection of early danger sings in newborns, to prevent and treat Diarrhea, Pneumonia and Malaria. He recommended applying Device X to the current Community Case Management system and the more mobile volunteer health teams. Mark Choono at UNICEF Uganda Country Office was really interested in using this type of open source technologies for emergency situations, such as for vulnerability assessment or employed by organizations like UNHCR to capture cross border movements and establish feedback of information to refugees, to allow for really focused interventions. Hugh Greathead, Grants and Relief Associate Director of World Vision, explained how they have been experimenting with the tracking of emergency supplies using palm pilots and PDAs (1500$ each) paired with a customized interface to monitor their relief aid programs. We discussed the obstacles he had encountered with the technology as well as with proprietary customized software solutions. He anticipates a hardware and software open source toolkit for emergencies to be something that could highly revolutionize the humanitarian sector. Langdon Greenhalgh, Project Manager of Global Emergency Group and I discussed the potential of Device X applied to emergency response and management of supplies. He pointed out how such device could not only allow sharing information like stock-outs, supplies distributed, supplies needed, but would also allow for warehouses to communicate and possibly share available supplies during emergencies in the most efficient way. Claire Riches, Programme Coordinator of Malaria Consortium discussed how they are employing cell phones and other hand held devices to track malaria. She seemed interested in creating lines of communication among all pilot programs and NGOs working on the territory. Her major concern about employing a device such as Device X for collecting malaria related data was the current prototyping phase, final cost and how soon this device could reach its intended audiences. During the meeting with the Advisor to President Museveni, I introduced Device X in the context of the new technological solutions that the UNICEF T4D team, at the Uganda Country Office, was testing and proposing to solve major challenges. Having a physical prototype helped the Advisor in visualizing the 

  6. 6. bigger picture of how all these platforms could come together to create a more reliable system of data sharing and off-the-grid connectivity. Suggested course of action moving forward Phase 0: RESEARCH Phase 1: PROTOTYPING Phase 2: TESTING Phase 3: ASSESSMENT & REPORTING PHASE 0: The next phase of this project should focus on more in depth research on current processes, cost analysis of production methods and options, and on continuing the conversation with local suppliers or already established suppliers for future material procurement. More research is absolutely necessary, especially on how data collection processes are being carried out today not only in the medical field, but also in the educational and supply control field as well. This research should include collecting additional Ministerial guidelines, flow charts on child and adult diagnosis and treatment, student and medical registries as well as medical dispensing logs, in order to translate the existing methods into programs that can be executed by and with the aid of the device. Examples of programs to be researched are: programs to monitor bed-nets distribution, school attendance level and productivity, childbirth registration, and HIV medical supplies distribution. Creating more executables for Device X would help in testing further concepts of this device and would help in extending its potential applications. In depth cost analysis and comparison of production methods is important at this point of the process to narrow down the best and most adequate choices of hardware and software architectures. We will compare customized hardware/software solutions against using preexisting, off-the-shelf computer solutions paired with a tailored system and a custom-made user interface. It’s also vital to continue the research and all communications with local hardware importers and suppliers, local Universities like the department of Computing and Informatics Technology at Makerere University or vocational training schools like the Nakawa Vocational Training Institute, in order to create relationships and possible partnerships with local facilities and begin the search for locally trained skilled technicians and programmers, to build capacity and create the basis for a long terms sustainable project. Part of the research should be focused on what environments this device needs to operate in and what kind of wear it needs to sustain. It is fundamental to conduct research on the methods of insulation and weatherproofing necessary, while keeping in mind what is locally available and the amount of training necessary to locally reproduce the same quality of product. PHASE 1: After researching the aspects listed above, we should have a much clearer idea of what are the most feasible directions the device should take in terms of hardware choices, as well as what type of programming will be necessary for it to operate. I suspect there are two main directions this prototyping phase should explore: A. An open source customized single chip, microcontroller solution with open source programming code and libraries that can be modified by the user according to the specific data collection application. For example: an AVR module, with touch screen interface, USB and Serial capabilities for attachments, GSM module and open source codes for different applications. Outside of the initial development and prototyping cost, a customized solution can result in a less expensive production process (if outsourced), a more flexible system, a final smaller size, a longer battery life, a public architecture and therefore a larger community of contributors. The programming of such device will most likely require a higher skill level and in depth training from 

  7. 7. the local technicians or a possible front end could be used to download customized codes onto the device directly, limiting the need for more specialized programmers. B. A system composed of preexisting, off-the-shelf hardware, together with a portion of customized electronics in order to interface the core processor with peripherals and other attachments. A customized software and UI will handle any user input in an intuitive and efficient way. For example: a small netbook or tablet, with open source Operating System, interfaced with customized and/or off-the-shelf USB peripherals running a custom-made application and easy to use interface. This solution offers more processing power; it is peripheral-friendly and presents lower initial hardware cost but higher software development and fabrication cost, with possible lower battery life, less durability and greater risk of theft. PHASE 2: After developing one or more hardware solutions, another in field experience would be important to contextualize the new prototypes and start the first actual user testing process. A second trip should focus its research on the data logging processes and on the most important challenges this device should tackle first, as well as more in depth user testing and interviewing practice to collect valuable information on what aspects worked and what didn’t. Much can be learnt from the things that worked, but much more from those that didn’t work out well for our intended users. These revisions would then constitute the blueprint for a more final and more refined prototype. During the trip, part of the focus should be to experiment with local suppliers and create partnerships with schools, facilities and distributors to test the feasibility of creating this device locally instead of manufacturing elsewhere but assembling it locally. Possibly having one device, or parts of one, locally built and assembled would be very important to compare quality and timeframe. PHASE 3: This last phase includes reflecting on the latest findings, a review of all discoveries, reporting on the latest experience in the field and the results of interviews and user testing. This phase should analyze objectively the results of the latest user testing and all user feedback, to decide upon the overall feasibility and usability of this device. These results and discoveries will constitute the starting point for the next steps and will lead towards the final process of development of Device X. Conclusions In conclusion, after the twelve-day stay in Kampala, Uganda, I strongly believe in the importance of immediate data analysis and in the need to make this data collection process more efficient and less time consuming. The repetition found in the manual transcription of the same information in a multitude of registries, the amount of errors that the current system is prone to, and the delay in paper data collection and processing, are all issues that Device X can address and resolve. A device such as Device X is needed because it can store information, instantaneously transmit and process data, it can be customized, it is easy to use, modular, low power, durable and weatherproof and it builds upon existing infrastructures. It also aims to creating a new economic outlet, thanks to the introduction of new skill sets and different training that can be applied to the local manufacturing and assembly of such devices. Device X fits very well with the current goals and the larger objective of the Technology for Development Team at UNICEF, as well as with the ultimate mission of the UNICEF Uganda Country Office: to keep children alive, safe and educated. As part of the larger goal, this device is an alternative input device that is portable, energy efficient, durable, of no apparent value and open source so that it can be interfaced and linked with other UNICEF current projects (such as RapidSMS and ChildCount), in order to create a complete system and toolkit to address a multitude of challenges that children in Uganda encounter each and every day.