A lot has happened in the last 6 months. Everyone involved with Mobiles in Malawi is excited by the SMS program’s impact on healthcare delivery at St. Gabriel’s Hospital. The medical staff and participating CHWs have taken ownership of the initiative, and what’s left of a public service grant will keep the program running for 10-15 years – at just $500 per year.
St. Gabriel’s is certainly not alone in the challenges it faces as a rural healthcare provider. After witnessing the effects of simple ideas and equally uncomplicated technology on medical care, one thing was clear – each day that a clinic goes without tools they want and need is a day with undue hardship.
To date, I am talking with healthcare organizations working in eleven countries (Burundi, Malawi, Uganda, Zambia, Mozambique, India, Kenya, Ghana, South Africa, Peru, and Haiti) about partnerships to expand the tools and strategies used at St. Gabriel’s to their respective sites. Details regarding these organizations and my role in supporting them will be expounded upon at jopsa.org in the coming weeks. In addition to healthcare providers, I’m honored to be collaborating with kiwanja.net, The kiwanja Foundation, the FrontlineSMS team, and MobilizeMRS.
After speaking with global health organizations and the clinics they’re linked to, it is clear that 2009 must be a year of action. Everything that happens will be posted here. I hope you’ll join me on this journey, and share your thoughts along the way.
This morning, we distributed the first batch of solar panels from G24 Innovations. I was also able to reconnect with CHWs I hadn’t seen in a while. Everyone was extremely happy – I’ll let the pictures tell the story.
Of course, Alex ran the session. The instructions were quick and easy, and everyone was rather celebratory:
To close the meeting, the CHWs sang a song for me that they had prepared – I’m not sure what the lyrics were, but “phones” and “messages” were included! Afterward, I traveled with Dickson Mtanga and Mary Kamakoko to their villages – it took a good two hours on a bicycle. We spent another 3 hours biking around and seeing patients, before I started back to the hospital. Dickson and Mary, using their new panels:
I’m back in my old room at the hospital’s guest house, and it’s pouring rain. I arrived just in time for the last Home-Based Care course – 21 new, volunteer CHWs were reviewing referral procedures, patient rights, the contents of their drug kits, etc. The group, seen above, is copying acronyms into their notebooks. Here’s a snapshot of what they’re writing:
At the end of the session, the CHWs were asked to turn in a piece of paper describing the location of their home. Most of their responses were paragraphs long – some included extensive maps.
Joanna, who is running PointCare’s CD4-count outreach program, relayed an interesting conversation with one of the CHWs a week ago. She traveled to their farthest site – a good 100 mile drive – and ran into Zakeyo, who said, “You know, Josh is coming on the 19th.” I checked FrontlineSMS, and Alex hadn’t warned him. It’s exciting to know that the next time I see him, I’ll pass along a solar panel accompanied by a solar-powered light.
Tomorrow, I’m going to spend some quality time with FrontlineSMS – working through the communication over the last four months.
Please comment freely, or shoot me an e-mail, with any questions. I have just two weeks before I return to Stanford, and I’m trying to make the most of it! As always, thanks for reading.
It’s amazing to see Alex and Grace on the site, and I think Steve wrote a wonderful article. I’m headed back to the hospital for Christmas break, and I’ll be updating the blog regularly – starting now. Here’s a (very) quick 30-second video, as a re-introduction to the project and a few of the people involved.
In 2008, FrontlineSMS was implemented as a central SMS hub for a rural hospital in Namitete, Malawi. Located 60 km from Lilongwe, St. Gabriel’s Hospital serves 250,000 Malawians spread over a catchment area 100 miles in radius. The vast majority of the people the hospital serves are subsistence farmers, living on under $1 a day.
• The catchment area has an HIV prevalence rate of 15% combined with widespread malnutrition, diarrhea, Multi-Drug-Resistant Tuberculosis (MDR TB), Pneumocystis pneumonia (PCP) and other opportunistic infections. Three medical officers are employed at St. Gabriel’s – creating a physician-to-patient ratio of 1:80,000.
• The hospital has enrolled over 600 volunteers to act as community health workers (CHWs) in their respective villages. Many of the volunteers are active members of the HIV-positive community, and were recruited through the hospital’s antiretroviral therapy (ART) program.
• When one ART monitor, Benedict Mgabe, was asked why he started volunteering, he replied, “I began when I saw my relatives and friends who were suffering from HIV and AIDS. I took it very personally; I knew I must get involved in curbing this epidemic.”
A need for a true community health network
Distance presents an often-insurmountable obstacle for patients seeking care at St. Gabriel’s. Many patients walk up to 100 miles to the hospital; those with more resources ride bicycles or oxcarts. In order to report patient adherence, ask for medical advice, or request medical care for remote clients, CHWs had to travel similar distances to the hospital’s doors.
The most motivated of the CHWs kept their own patient records, and journeyed to the hospital every few months. Their activities effectively isolated by distance, the impact of the volunteers’ work was restricted to their communities and disconnected from the centralized medical resources at the hospital – their potential role delivering healthcare stifled by disjunction.
Implementing the project
During the summer of 2008, I traveled to St. Gabriel’s with 100 recycled cell phones and a copy of FrontlineSMS – a free program developed by Ken Banks to act as a central text-message hub. My plan was to implement a text-based communications network for the hospital and the CHWs.
In groups of 10-15, CHWs were brought to the hospital, given cell phones, and trained in text messaging. The volunteers’ locations were mapped, and the phones were disseminated throughout the catchment area.
Stationed at the hospital, a laptop running FrontlineSMS coordinates the health network’s activities. The day-to-day program operations were handed over to hospital staff within two weeks. FrontlineSMS is operated by Alexander Ngalande, a nurse who heads the hospital’s Home-Based Care program.
Mr. Ngalande, on setting up and running FrontlineSMS:
“It was very quick. And, people didn’t know that this thing could work here – because, it’s our first time to have this kind of system whereby people can directly communicate with the hospital using FrontlineSMS. It’s simple and straightforward.”
Impact on patient care and hospital operations
The SMS network has enabled the following:
• Requests for remote patient care
CHWs text the hospital staff when immediate care is needed, and the patient is subsequently visited by the Home-Based Care mobile unit. Patient location and health status are communicated, allowing the mobile team to bring needed drug supplies. According to Dickson Mtanga, a CHW in the pilot program, “When I have a problem with my patient, I just send a message to the hospital, at once. If they are helped and assisted, I feel so much better.”
• Patient tracking
The hospital is now able to track patients in their distant communities. According to Mr. Ngalande, “Each and every department is free to use FrontlineSMS. We have ART, Home-Based Care, TB, PMTCT (Prevention of Mother to Child Transmission). For example, TB patients who are not coming for their appointments, we use FrontlineSMS to text volunteers close to the patient’s village. It’s easy to get feedback from the community.”
• Checking drug dosages
CHWs in the field have been given basic drug supplies (e.g. Panadol, Ferrous Sulfate, eye ointments) for primary care. The CHWs now check drug dosages and uses within seconds. When FrontlineSMS receives an SMS with a drug name, it automatically responds to the health worker with that drug’s information.
• Patient updates
CHWs regularly update the hospital staff with regards to patient status, including reporting patient deaths. These messages have created a post-discharge connection to patients’ well being.
• Coordinating Home-Based Care visits
In addition to responding to medical emergencies in the communities, the Home-Based Care (HBC) unit also follows a schedule of home visits – sometimes checking on patients have been discharged recently. Other patients are enrolled in the hospital’s palliative care program. Before traveling to the patients’ villages, the mobile unit text messages CHWs in close proximity to the clients they plan to visit. Any response by the CHW (e.g. “Patient is not at home.”) is forwarded to the mobile team’s phone, allowing medical staff to maximize their productivity by visiting available patients.
• CHW-to-CHW communication and group mobilization
CHWs are now communicating and collaborating. All texts are shuttled through the hospital, and FrontlineSMS commonly relays messages and requests between CHWs. This has been an important function in setting meeting dates for Village AIDS Committees and linking HIV/AIDS support groups. Hospital activities throughout the catchment area (including microfinance and Positive Living programming) are organized using the SMS network. Baxter Lupiya, a CHW in TA Kalolo, notes, “We used to travel a long distance. Now, we have easy communication with others. The program must be continued, because it is so good!”
• Integrating connectivity into HIV counseling
HIV Counseling and Testing (HCT) at the hospital has been augmented because of the SMS network. If a client tests positive, he or she is paired with to an HIV-positive CHW with a phone – these volunteers act as models for Positive Living and provide comfortable, relatable links to the hospital.
• CHW status
The connection to hospital services has solidified the CHWs’ role as legitimate healthcare representatives in their villages. The patients and their communities, according to the program’s participants, have noticed the phones, each one clearly marked with the hospital’s logo.
• Incentives and accountability
The phones provided very concrete incentives for the volunteer work done by the CHWs. The SMS network created, for the first time, a way to track the CHWs’ activities, paving the way for more informed decisions regarding allocation of resources (e.g. which CHWs should receive bicycle ambulances).
A whole-hearted thanks goes out to everyone who has been reading these posts. I’d be thrilled to hear from you. In the next few days, I’ll put up a post that will (attempt to) cover the various, exciting ways this project is moving forward. In the next week or so, I’ll also be developing a DIY guide, based on a series of FAQs – much more on this later.
As promised, here is an interview with one of the Community Health Workers involved with the pilot in Malawi. Verona speaks on why she started volunteering, how the SMS program has changed her ability to care for patients, and what it means to be a healthcare volunteer.
Here are a few of the messages sent to the hospital by Verona, in the first weeks of the pilot:
AK has a problem of CCF; his medicine is finished, and he is getting a bit better.
AJ is on TB treatment, he is taking the drugs following instructions. He is improving. AM had swollen thighs but she is improving. She is taking drugs following instructions – the guardian is strict.
Adherence: TN is alright. He is taking the drugs following the instructions, he did not miss any day.
PT is very fine, working hard in the garden. He did not miss any day.
After a few days of traveling, I’m back at Stanford. It was difficult to leave Namitete, but there’s plenty to be done in the US.
Below, I’ve uploaded an interview with Alexander Ngalande, the hospital’s Home-Based Care nurse, regarding his experience with FrontlineSMS. Please excuse the poor quality – my equipment was limited to a small, digital camera.
Over the last week, there’s been a cascade of communication. A few examples, of many:
- A man missed his appointment with a TB officer. A CHW was texted, who reported the man had gone to Zambia for a funeral. The hospital will be notified upon his return.
- An HIV support group met, and decided on new member guidelines. Via SMS, the group leader asked the hospital to print copies for the lot.
- A CHW asked about ferrous sulfate dosages, so he could administer the proper amount to an anemic child.
I’m at the halfway point of my trip, and after five weeks on the ground, a discussion of the tools is in order. Ken Banks, the creator of FrontlineSMS, recently wrote an article about the emerging social power of mobiles for BBC News:
Ken is building a community of implementers. Interested parties should visit two of the group’s sites: www.kiwanja.net and www.frontlinesms.com.
It is precisely due to FrontlineSMS’s smart simplicity that the project has developed organically – first and foremost, to meet the hospital’s needs as it serves its catchment area. The quick uptake of the project was fueled, in no small part, by how user-friendly FrontlineSMS is, as a central communications hub.
It also has provided solutions to some potentially tricky questions. A quick example:
Text messages cost 10 cents. Units can be sent from one phone to another via Celtel’s Me2U service, but managing the units of 100+ phones manually is near impossible. So, I had to find a way to both monitor each phone’s unit level and top up (replenish depleted reserves) automatically.
Before leaving Stanford, I engraved each phone’s faceplate with a two-digit ID number. Using FrontlineSMS’s auto-forward function, I’ve set up a system to automatically top CHWs up. When they are running low on units, CHWs can text “(ID number) Units” to FrontlineSMS. Subsequently, a message is sent to Celtel, with instructions to top up that particular CHW. System abuse is unlikely and avoidable – the volunteers know that FrontlineSMS records every message received, sandwiched by unit requests.
We’re starting to explore additional functionalities of FrontlineSMS. Each CHW is given a kit of basic medications – a portion of the questions we’re fielding involve those drugs. We’ll set up an auto-reply system so that any message containing a given drug name returns a summary – function, dosages, etc. – for that drug.
This week, another group of jubilant CHWs was trained in texting. Below, you can watch a one-minute excerpt of the training session – Alex is explaining the first steps in operating the phone. At the end, you’ll hear a chorus of ‘success sounds’ – all the phones turning on for the first time by their owners’ manipulations.
The week has gone very well, and the project’s initial success has been noticed by each arm of the hospital. I took a minibus into Lilongwe, which turned out to be a fruitful venture – I rode into Namitete on a bike taxi wielding extra maps, an assortment of push-pins, and a few surge protectors (which will establish a permanent location for CHWs to charge their phones at the hospital).
Each CHW we train and distribute a phone to will be placed on a map of the hospital’s catchment area, with a different color pin, depending on their program (Home Based Care, ART Monitors, Reproductive Health Volunteers, Counseling, or Youth Volunteers). Particularly committed volunteers assume multiple roles in their community – they’re distinguished by blue pins. The idea is to have the maps, with hundreds of CHWs’ locations marked, displayed clearly for the clinical staff at the hospital. This way, a clinician looking to track down a patient need only consult the map, find the nearest, appropriate CHW’s identifying number (written on the pin), and send out a text. Here are the new maps, along with the locations of the first 20 dispersed phones:
Tomorrow afternoon, I’m attending the staff meeting for those involved with the hospital’s antiretroviral therapy (ART) program. I’ll be explaining the project, and the group will determine a protocol for communicating with adherence monitors in the field. Below, you’ll see me, sitting with Grace, who coordinates the hospital’s ARV provision.
As always, thanks for reading. Any ideas, as this expands?
I was excited to hear that PC World picked up an article that Ken Banks (founder of kiwanja.net, and the man behind FrontlineSMS) wrote, titled, “Witnessing the Human Face of Mobile in Malawi.” If you’re interested, you can read it here.
We’re ready to expand a bit. We heard from every one of the CHWs in our pilot group (some, many times). In just a few days, we saw some tangible results. Here’s one example:
Verona Kapagawani, who lives in TA Mavwere, alerted the hospital that a patient had run out of his meds.
A nurse at the hospital, familiar with the patient, responded that he should fill his prescription (he has chronic congestive heart failure) as soon as possible.
Verona responded, noting that she counseled the patient. He wasn’t feeling well enough to travel, so she came to the hospital to pick up his drugs.
While chatting with the nurse, Verona charged her cell phone.
I ran into another CHW, Benedict Mgabe, at the hospital today. He’s the chairman of the Community AIDS Committee, and he’s texted me every day. With a smile on his face, he shook my hand and said, “This is a very good program! It is really helping us a lot.” Those short sentences confirmed that I want to have longer conversations with the CHWs, to gather their reactions.
We’re using the pilot group to contact the next wave of CHWs, another 10 volunteers, to be trained and given phones Monday morning. Above, you’ll see Alex (a nurse, who does most of the Home-Based Care community work) and Grace (who coordinates the ART program) using FrontlineSMS to text the group.
I had a long discussion with Dr. Mbeya, the medical director at St. Gabriel’s, about making very definitive links between the hospital and the CHWs’ activities. As the project grows over the next weeks, we’ll create guidelines for reporting and follow-up, based on the specific program. For example, the hospital has a lively prevention of mother-to-child transmission (PMTCT) program, aimed at reducing vertical transmission of HIV. We’ll develop a protocol for utilizing the CHW network to follow up on mothers who’ve missed their appointments, and the CHWs will provide a link to the communities’ pregnant population.