I sat down with Alex today, to discuss the FrontlineSMS and its impact on the Home-Based Care (HBC) program at St. Gabriel’s. Essentially, he’s a one-man, mobile care unit – focusing on chronically ill patients and those who simply cannot travel to the hospital. The backpack, pictured above, is full of medical supplies.
The SMS network has brought Alex to the homes of 130 patients who would not have otherwise received care. That’s about five responses, per week, to requests for remote medical attention.
Before the SMS program, Alex was visiting around thirty patients a week, rotating through the HBC roster. He now follows up on five patients per week, usually checking in on those who have been recently discharged from the hospital. The CHWs take care of the rest – since the program started, approximately 520 HBC patient updates have reached the hospital via SMS.
The difference in Alex’s HBC activities amounts to about 500 hours and over $1,000 in fuel saved. He has responded to ~40 requests for healthcare supplies (usually dressing materials for wounds and cervical cancer patients). With FrontlineSMS blasting automated responses to drug inquiries and Alex responding to questions regarding basic care, the central SMS hub truly serves the CHWs and their patients.
Alex, who is a highly capable nurse, also holds full shifts in the male ward at the hospital, and is one of two staff members coordinating antiretroviral treatment (ART) for the catchment area. His multitude of responsibilities make time saved in managing the Home-Based Care program extremely valuable.
The first batch of solar panels from G24 Innovations (www.g24i.com) arrived today – I tested one of the products and it quickly charged my phone, to completion, amidst a thunderstorm. More on this later – we are gearing up for training and distribution on Monday.
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.
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.
I promise I’ll explain the title – in a bit. First, here’s a re-cap of some of the week’s developments:
Above, I’ve provided a snapshot of today’s activities in the Home-Based Care (HBC) office, the new home of FrontlineSMS and the CHW maps. From left to right – Neggie, a nurse in labor ward; Grace, the hospital’s ART coordinator; Alex, the HBC nurse. Neggie showed up at the office with a list of mothers – they were enrolled in the hospital’s PMTCT program, but they’ve failed to report for their 6-week follow up (when blood samples are taken in order to determine the child’s HIV status by DNA PCR). Alex is locating the mothers’ villages, and reading off the ID numbers of CHWs in their vicinity.
These days, the majority of the patient visits made by the mobile team are responses to SMS requests for immediate medical attention. Still, certain visits are scheduled follow-ups after patients have been discharged. Traveling with Alex, I realized that, at least half the time, the patient is nowhere to be found. Alex now sends a few quick messages to the CHWs overseeing the patients he’s planning on visiting, letting them know he’ll be stopping by. While he’s out in the field, any response from the CHWs is forwarded to his cell phone. This assures that he sees patients who are available – and avoids 40-mile journeys to discover a patient is away, selling maize in Mozambique.
A CD4 outreach initiative funded by the World Bank starts up later this week. They will use the CHW communications network to inform villagers of testing sites and dates – aiming to increase client turnout, thereby bolstering access to the free testing services.
This past Saturday, we gathered the first 30 CHWs for a refresher course – explaining the automatic unit top-ups and the drug keywords (we’ve already had BB Paint, TEO, Panadol, and Multivitamin info requests). After the session, I video-interviewed four of the CHWs, in English.
I’m leaving Malawi this coming Friday, and when I’m back at Stanford I will be uploading the videos. I’m planning to embed them in individual posts – so you can hear the stories of care from those who have lived them. Their general attitude might be described as thankful, yet realistic about the pressing needs of their families and friends – hence, the title of this post. Malawians are said to spend roughly 10 percent of their waking hours at funerals. The statistic does reflect troubling times – but it also demonstrates the blurred boundaries between family and fellowship. Villages are full of brothers, sisters, and mothers – some share heredity, but all share circumstances. Every text message sent by the CHWs has invited me to appreciate the true meaning and function of community.
A baker’s dozen left St. Gabriel’s Hospital on Thursday with cell phones, trained and ready to communicate. Below, a CHW practices texting “Malawi.” He’s the Home-Based Care provider in his village, and runs an orphan care center.
Text messages are notorious for being concise, hence the Short Message Service (SMS) protocol and its 160 character/message cap. Most of the messages to and from the hospital are brief, and to the point. Some CHWs, however, send stories – sometimes, five messages in length. A few examples (translated from Chichewa):
PF is refusing to use the condoms in his family which has made his wife to be pregnant of three months and he also drinks alcohol much, and also likes women. In so doing I advised him not to stop using condoms and also to stop drinking because they are putting his life in danger. And his wife should start going to her doctor visits, like at St. Gabriel’s.
I found TJ smoking, and he is on TB medication. He failed his first treatment in 2006, and this is his second treatment. 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.
Both of these CHWs texted for the first time a little over a week ago.
I’m planning to video-interview a few of the CHWs this Tuesday and Wednesday. Any questions for them?
I thought I’d post it in Chichewa, to document its original form. But, it translates roughly to, “There are two patients, very sick of cancer.” Tomorrow, Alex will take the hospital motorbike to Chilembwe, about 60 km away, to check on the patients. A quick text let Zakeyo know to expect him.
From Baxter Lupiya – “Natenga ma A R V omwe anasiya aMwinama, omwe amamwalira dzulo. Ndibweletsa la chisanu. Zikomo.” Translated, “I have collected the ARVs left by a patient who has died, and I will return them to the hospital on Friday. Thank you.”
From Benedict Mgabe – “Mai laulentina adamwalira pa sabata kwa chamoto omweanali pa pa h.b.c.” In English, “Laulentina, a patient in the Home Based Care program, died on Saturday.” Terrible news, by any measure, but it saves the hospital a day-long trip to Chamoto to give Benedict more morphine.
I can’t help but envision each of the hospital’s 600 CHWs with a phone in their hand, the hospital’s number saved as cherished contact.
Any thoughts? I hope all is well, wherever you might be reading this.