On Christmas morning, Silia stopped by the guest house to talk about the SMS program. He’s responsible for testing, drug provision, and follow-ups for TB patients. He described how he’s using FrontlineSMS and the network of cellphone-wielding CHWs. Almost all of what follows developed in my absence.
Some sputum-positive patients don’t turn up to receive their medication. It’s Silia’s job to track these patients and get them back on their drug regimens. Before the SMS program, he was visiting an average of 17 patients per week – this took him three trips on his motorbike. Each trip would take ~9 hours. That’s 27 hours per week spent tracking patients in various villages.
The SMS network has allowed Silia to share his workload with the CHWs. He now tracks an average of 20 patients per week via SMS. He simply texts CHWs nearby patients that haven’t turned up. As Silia says, the CHWs provide “immediate feedback.”
The program has been running for roughly 26 weeks. With the shift to SMS-based patient tracking, Silia had an additional 700 hours to utilize. Not surprisingly, he’s been using FrontlineSMS to supplement other areas of his work.
He now visits an average of 4 patients per week, for different reasons. Some messages from the CHWs tell of patients who are too ill to travel to the hospital. Silia will respond by bringing a new supply of drugs. Other messages relay symptoms of community members – e.g. “A man has a chronic cough, and we suspect TB.” Silia will visit the patients, and collect a sputum sample. He’ll return to the hospital to do testing and send the results, by SMS, back to the CHW.
Finally, when patients at the hospital test positive for TB, they’re told which CHWs near their home have cell phones.
Some numbers from the TB program for the last 6 months:
700 hours of follow-up time saved 450 follow-ups via SMS (At least) $2000 in motorbike fuel saved 100 new patients enrolled in TB treatment program
Coming up: Impact on Home-Based Care, PMTCT, Public Health, and HIV/AIDS programs
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.
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?
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.
Above – another happy group of health workers, the program’s newest inductees. By the end of next week, there will be 50 phones in the field – next Wednesday, we’re adding Reproductive Health and Youth Counseling volunteers to the network.
Below, you’ll see some of the CHWs re-teaching SMS steps to the rest of the group – a key component of the training sessions.
Once the session ended, a few of the CHWs reviewed their notes:
Walking through a village this afternoon, I happened upon three separate barber shops, each advertising Phone Charging services.
Malawians understand mobiles. It’s time to put the technology to work.
Next week, amid further CHW orientation, we’re holding comprehensive training sessions for hospital staff – so that TB officers, ART directors, pediatric nurses, PMTCT coordinators, clinicians, and VCT volunteers alike can use FrontlineSMS to contact the CHWs.
Today, Alex and I headed into the field. The goal was to find seven patients – the hospital had been alerted of their declining health, by SMS, through seven different CHWs. The motorbike-enabled, text-message-guided journey through the catchment area completed a (once) theoretical cycle: The CHWs surveying communities, then communicating their most urgent needs; the hospital gathering resources (diesel, drugs, and medical advice), then traveling to the villages.
Often, we stopped by the CHW’s home. Above, Pascalia directs Alex to the patient’s location. After the picture, she ran home, put on her St. Gabriel’s Hospital ‘Positive Living’ shirt, and joined us for the consult.
A brief overview of some of the cases:
- An HIV-positive man, on ARVs, with Karposi’s Sarcoma and wet beriberi.
- A 13-year-old girl with stomach cancer and massive ascites. Pascalia is the closest CHW, but her bicycle ‘ambulance’ is not operable. So, we texted Moreen, who is just a few villages away. She’ll bring her ambulance, and get the girl to the hospital.
- A 72-year-old man, who is sputum-positive for TB, and was complaining of severe joint pains.
- An man, suffering from epilepsy, fell into a fire two weeks ago. He has developed a massive ulcer on his left heel. Left, Alex is explaining how to wrap gauze. The man happily let us take a picture of the scene.
We met with the hospital staff when we returned – after traveling 100 km in 6 hours, and visiting 7 different villages. Everyone agreed that the day was a success.
The entire hospital staff is now fully aware of the project and its goals. We’re all moving in the same direction. The consensus is that a second, simple cycle, once disseminated, will greatly aid follow-up and monitoring programs: The medical staff (looking to follow up on a TB patient, for example) consulting the CHW map, and contacting the nearest CHW; the CHW checking on the patient, and responding to the hospital re: their status.
Back row, Left to Right: Harold Malanga, Benedict Mgabe, Zakeyo Kaphanthengo, Joana Chimphanje, Pascalia Chiwinda, Moreen Phiri, Verona Kapagawani, Baxter Lupiya Bottom row, Left to Right: Dickson Mtanga, Grace, Alex, Rosemary Bernado
I have to believe today’s events were endowed with the elements of a promising beginning. The first phones are in the field! Before I get too ahead of myself, let me explain what’s put me in such an optimistic mood.
We called the chairs and vice-chairs of the volunteer committees (Community AIDS Committee, Village AIDS Commitee, and the People Living With HIV and AIDS [PLWHA] support group) for a meeting at 9 am this morning. The came in together, some on bikes, most on foot. Considering that some traveled over 50 miles (that’s most definitely an underestimate), this was quite the event.
I had been up since 6:00, testing phones and FrontlineSMS, and I was eagerly awaiting the group – equipped with Cokes, Fantas, lemon cookies and a broad smile.
We met in the old Nutrition Rehabilitation Unit, which had been stocked with assorted chairs. After everyone sat down, the hospital’s matron greeted the group. After making sure each of the CHWs could understand slow English, she opened the meeting:
I know that times are difficult, but we must make improvements step by step. Do babies just start to run? No, they start just sitting. Then, when they see something beautiful, they wiggle their stomachs and arms, trying to reach for it. Soon, they can crawl; then they start walking. We can take steps forward, together. This is a pilot – we are learning new vocabulary today, too! You are the first to do this. It is not enough to try. We must do it.
After that poetic introduction, the matron told them they’d be receiving cell phones. This news was greeted, almost immediately, with cheers and applause.
The matron handed the ecstatic audience over to Alex and me, and we explained how to operate the phones (Alex is a male nurse, who works within the Home-Based Care program). I had every single ounce of the audience’s attention, as I started, “First, just open your phone!”
*A disclaimer: That’s Alex’s handwriting.
We had an outstanding time teaching the CHWs how to use the phones. It started with group chants of, “Messages! Compose Message! New Short Message!” The majority of the CHWs hadn’t texted before, so we spent some time teaching them – by the end of the session, each of the health workers flawlessly typed ‘St. Gabriel’s Hospital,’ apostrophe and all.
After a few hours of rigorous concentration and seemingly inexhaustible patience, we took a break for snacks. During break, we discussed logistics.
The CHWs all claimed to have access to electricity. It seems that most will have to pay 10 kwacha (a few cents) to use the nearest electricity hub. When it’s necessary, they (or someone from their village) will travel to the hospital to recharge the phone, free of fees. This isn’t altogether rare, as the CHWs often accompany patients to the hospital.
After the matron and Alex explained baseline expectations for communication, the CHWs took over the meeting. Pascalia and Verona, the two Community AIDS Committee chairs, were especially emphatic. Pascalia stood, declaring, “The hospital does what it can to help the volunteers. We must do what we can to work hard. Remember, just because we are the ones who came to the hospital today does not mean the hospital loves us more than the others.” Verona responded, looking straight at me and pumping her fists, “I will work much harder!”
The frequency and type of communication the CHWs will maintain with the hospital will depend on the program the CHW is enrolled in. For example, those involved in TB drug adherence monitoring will alert the hospital when a patient is deviating from a regimen. Similar expectations were agreed upon for the ARV monitors. Home-Based Care volunteers will be messaged when a patient needs to be traced or if a follow-up is needed. Those involved in organizing peer support groups will use the system to coordinate meeting times and locations. With any luck, and plenty of commitment, they’ll be a working network of CHWs, with St. Gabriel’s Hospital as a coordinating agent.
Before leaving, the group sent a sample text to the hospital’s number, and we showed each CHW their respective message as it popped up in FrontlineSMS. It was an animated scene, for sure. I recorded some of their information (name, number, village, and respective program), checked their starting units, and let them loose on the catchment area.
Needless to say, I’m looking forward to tomorrow, and the possibility of the first messages trickling in. With a smile on her face, Verona asked me, “So, when can we start messaging?” A few of the CHWs joined me in responding, “Now!” As they started home, I could see they were exchanging phone numbers.