FrontlineSMS Update for Malawi's Ministry of Health Data Standards Meeting
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On Thursday, February 4th, I had the fortunate opportunity to present at a National Data Standards Meeting, convened at the Cresta Hotel in Lilongwe by Chris Moyo of the Central Monitoring and Evaluation Division of Malawi's Ministry of Health. These slides offer a brief overview of FrontlineSMS:Medic's evolution in Malawi, the current work that has kept me busy for the last six months, a few lessons learned, and some of our vision and strategy for the future.
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FrontlineSMS Update for Malawi's Ministry of Health Data Standards Meeting
- 1. Isaac Holeman, Field Director at FrontlineSMS:Medic contact: isaac@medic.frontlinesms.com web: http://medic.frontlinesms.com Malawi phone: 265-99-364-3347
- 2. Addressing rural infrastructure challenges
- 3. Community health workers build bridges between clinics and communities, but are often just as disconnected as the patients they serve
- 4. World’s fastest growing piece of rural infrastructure
- 7. Focus on technology and human resources that are proven by local markets and client demand
- 8. FrontlineSMS is the oldest and most widely used text messaging platform designed for grass roots NGOs. It serves nonprofits and governments for purposes ranging from health care to elections monitoring.
- 9. Free software for a laptop or desktop computer
- 10. GSM modem connects computer to mobile network
- 11. FrontlineSMS: a laptop and a cell phone become a communication hub
- 12. Training: start with basics
- 13. Pilot group: 75 health workers managed by a nurse who had never used a computer before
- 14. Impact in six months: 1. Saved $3,000 in motorcycle fuel 2. Saved 2,000 staff hours. 3. Increased volunteer enthusiasm & volume of referrals
- 15. Neno District - Ministry of Health and Partners in Health “ Every Monday, Dyson Likoma, APZU data manager, generates a report with a list of patients. The report is checked for accuracy and then text messages are sent to the VHWs responsible for the patients needing follow-up. The VHWs then visit their patients and send a text message response with their patients’ status, typically within 24 hours.” source: www.pih.org
- 17. Machinga District - Ministry of Health and Clinton Health Access Initiative
- 18. Decentralizing Hubs to health centers
- 19. Management Sciences for Health Basics and Family Planning Programs 4 Forms 10 Districts 500 HSAs Two Month Lag in Reporting
- 20. HSAs enter data into forms on Java enabled phones
- 21. Forms sent via SMS to district hubs, then uploaded to the Internet for offices in Lilongwe
- 22. Digital maps can replace paper-based tracking of disease burden & health services
- 23. stopstockouts.org mapped medicine stockouts
- 24. What Next?
- 25. Isaac Holeman, Field Director at FrontlineSMS:Medic contact: isaac@medic.frontlinesms.com web: http://medic.frontlinesms.com Malawi phone: 265-99-364-3347 Thank You
Editor's Notes
- My name is Isaac Holeman, I’ve been working in Malawi for about six months. I work with FrontlineSMS:Medic, an organization that I co-founded to provide technical assistance for health care organizations that want to improve communication and quality of care using mobile devices. We started working in Malawi in June 2008, at St. Gabriel’s Hospital. This presentation can be found and downloaded at: http://www.isaacholeman.org/2010/frontlinesms-malawis-ministry-of-health-meeting
- St. Gabriel’s Hospital deals with infrastructure challenges that are common in Malawi and much of East Africa. Their patients are spread out over a 100 mile area, and these patients often lack transportation to reach the hospital. Cases like malaria or malnutrition often reach the hospital very late, it is difficult to follow up with ART, TB, or other patients who have missed appointments, and stock outs of essential medicines are common at village clinics because it may take months for reports from hard to reach areas to arrive at district hospitals. St. Gabriel’s was able to purchase a motorcycle for their home based care program, and here you see Alex Ngalande, a home based care nurse about to carry a box of medicines to some remote patients. The motorcycle is a great help, but it is inefficient because gas is expensive, and Alex often drives 20-40 kilometers only to find that a patient or outreach worker has left to buy rice in another village, or that they are not in need of the medicines he had intended to restock, or that they had been out of the medicines for weeks and he hadn’t known.
- Like many Malawian health organizations, St. Gabriel’s also recruited hundreds of community volunteers to help coordinate care in remote villages. Volunteers check in on TB, ART, and home based care patients, counsel their peers to attend necessary hospital appointments, refer malnourished children for care, and inform the hosptial of community needs. Unfortunately, these volunteers were just as disconnected from the hospital as the patients they were caring for, and often they would return to the hospital only once a month or even less frequently.
- To combat these basic infrastructure challenges, we assited St. Gabriel’s in using the world’s fastest growing piece of rural infrastructure - mobile phones. Cell phone use is growing faster in Africa than in any other part of the world. In particular, SMS is useful in rural areas because it is inexpensive, it does not cost as much as voice, a rural health worker can send a text message even if someone at the hospital is busy and cannot respond to it immediately. These three phones from left to right: Nokia 1200 - This or the 1208 (very similar) are my favorite low end Nokias. Simple, durable, great UI, mutiple phone books, and flashlight. About $26 per phone in Malawi. Nokia 1680 - This is my favorite of the java enabled phones that can run the FrontlineForms client, as well as my personal phone. Super long battery life, durable, rubberized keypad. Runs from $45 in Kenya to $55-70 in Malawi. Zain ZTE - these are the mass market phones that Zain (the larger of Malawi’s two telecoms) sells for $13/phone. They are not as pretty or durable, but they are a great tool for the price, and are by far the most prevalent phones in Malawi.
- Cell phone use in East Africa is growing so quickly because local entrepreneurs have made all kinds of adaptations to market phones even in the remote areas. This is an example of a hut where you could buy a phone, a SIM card, or topup.
- Mobile phone use is possible in areas that do not have access to the electric grid thanks to charging stations like this one. Often they are based on car batters, so people can come to their local shop to charge a phone for 50 Malawi Kwacha.
- Our approach with FrontlineSMS:Medic is take advantage of the inexpensive tools that local economies have already proven to be viable. Making our entire system extremely simple and low cost increases the possibility for the system to be replicated because it is a “lowest common demonator” approach. Systems designed for the more remote and low resourced settings can also work in more connected and high resource settings, but the opposite is not true - a system this is too expensive or that relies on Internet cannot work in the poor rural areas. We are able to work in areas that do not have Internet or reliable grid electricity, and we are able to utilize and extend local skills and knowledge, rather than starting from scratch with every technical training. Note: due to time constraints this slide was excluded from the February 2010 Data Standards Meeting at Cresta Hotel in Lilongwe. Graph courtesy of Ken Banks - www.kiwanja.net
- FrontlineSMS was originally designed for many uses, from elections monitoring to human rights reporting to health care. It is both free and open source; it can be downloaded at www.frontlinesms.com. More recently, less than two years ago, FrontlineSMS:Medic formed to provide technical assistance and improve the FrontlineSMS software for health care uses. Picture of map from frontlinesms.com
- FrontlineSMS can work on most laptops (windows, linux, or mac), on inexpensive $300 netbooks, or on the older desktop computers that many Malawian district level statisticians (HMIS offices) currently use.
- You also need a GSM modem that will enable your computer to send and receive text messages. For example, the Huawei E220 can be purchased locally from Zain for about 27,000 MK ($180-$190 US).
- This computer and GSM modem then become a communications hub that allows you to reach out into the community. The next step is to get mobile phones out in the communities.
- When we started at St. Gabriel’s, about one in ten of the volunteers already had phones. We decided to provide each volunteer with a free phone, and we started training with basics such as how to turn a phone on, how to care for it, how to send and receive text messages, and how to request units from the hospital. We used a co-ownership model - as long as volunteers were active in the program they were welcome to buy their own units and use the phone for personal use. If a volunteer sends a text message requesting more units, the FrontlineSMS software automatically adds 100 units to their phone, and hospital staff are able to monitor unit requests to ensure that the system is not abused.
- Starting with very basic training was just as important for our program manager because he had never used a computer before. The software interface is simple enough that he learned to use the computer and could manage the computer independently after just a few weeks. For the first year of the program we involved 75 health workers. Health workers were given the broad request to send text messages about following up with patients, or any other health issue in their community that they thought it was important for the hospital to know about. The program has evolved over time, and now most messages relate to following up with ART, TB, or home based care patients, requesting non-emergency field visits, referring malnourished children, requesting drug restocks for community medicine kits, reporting deaths, or tracing any patient that has missed an appointment at the hospital.
- In the first six months the SMS program increased efficiency and volume of referrals, and had a big impact on volunteer enthusiasm. The phones were a good incentive, and the volunteers were proud to be a resource for their community. Alex saved a lot of motorcycle fuel because now he sends an SMS to a community health worker before visiting a remote area to ensure that they will be present when he arrives and they will help him find patients. Rather than driving around periodically to check whether communities are out of essential medicines, Alex focuses on driving to places where his presence is requested. $3,000 may not seem like much money for a district hospital, but it is more than it costs to operate the SMS program for one year. Most of the staff hours saved were of the volunteers who no longer needed to walk or cycle to the hospital to deliver information, but it also saved outreach teams much time because they were no longer making unnecessary community visits or driving to communities and not being able to find the person they were looking for. Increased volume of referrals was especially clear in the TB program, which increased in enrollment by 50 people (almost doubling in size) during the first six months of the SMS program.
- Since the initial pilot at St. Gabriel’s, we have begun assisting several other partners in Malawi. Here I will give a brief over view of some of the projects and things we learned or experimented with at each site. Partners in Health currently has 120 paid community health workers in a SMS program that is focused on ART, PMTCT and maternity care. PIH’s use cases are more focused than St. Gabriel’s. They have an advanced electronic data system and they quickly follow up with patients who have missed appointments. While almost 100% of patients enrolled in their PMTCT program continue the program effectively, we actually found that it was more difficult for the community health workers to focus on a too narrow number of use cases. At St Gabriel’s volunteers could be asked to follow up on TB, ART, surgery patients, or any number of other cases, and the extra practice helped them be more confident and effective cell phone users, and kept enthusiasm for the program high.
- Neno was also the first place in Malawi where we introduced small solar phone chargers (although this photo is not from Neno). Community health workers can charge their phones in the villages on the car battery based chargers, but this costs 50MK per charge (about 33 cents US). We can now get a solar charger shipped to Lilongwe for about $9 US (the cost of 30-40 charges). It takes about 2-3 hours of sunlight to charge a phone.
- The project in Machinga is our largest yet, involving about 360 community volunteers. As of February the project is still just beginning - phones are in the field and the system is live but we have not even distributed the solar panels yet.
- One exciting aspect of the Machinga project is that we believe it is among the first electronic data systems to be decentralized to the level of health centers in Malawi. In addition to the district hospital, we have communication hubs at three health centers. This was important because Machinga has decentralized PMTCT care to the health centers to bring care closer to the communities. This means that the supervising H.S.A. at each health center is responsible for following up with patients who have missed appointments at their health center, and we wanted to put this powerful follow up and community outreach tool in the hands of the person responsible for follow up. Decentralizing to the health centers also brings many challenges because cell phone network is poorer, grid electricity is poorer, facilities may be less secure and are more difficult to monitor, and staff tend to be less familiar with using computers. We are excited to watch this program develop and see what continued training and support is necessary to support electronic data systems in the villages. FrontlineSMS also has basic records keeping functionality, and in the future we see it filling a niche in data management for health centers and hard to reach areas, in contrast with more complex electronic data systems such as Baobab or OpenMRS (www.baobabhealth.org www.openmrs.org) which are more appropriate for district level or central hospitals.
- I am currently beginning work with Management Sciences for Health on a USAID-funded project to improve reporting from hard to reach village clinics, focusing on community based care for children under five, as well as family planning. Currently, on February 5th 2010, the central office in Lilongwe has received less than 2/3 of reports that village clinics were supposed to submit at end of 2009. Many of these reports will never arrive or will be incomplete and currently there is no system for retrieving lost reports.
- In the new system, HSAs (Health Surveillance Assistants) will enter data into a FrontlineForms application that we built for java enabled phones. While FrontlineSMS can normally be used with any phone that sends and receives text messages, the forms software can only be used on certain java enabled phones like the Nokia 1680 (pictured above), that cost around $55-70 US. The menu for the application appears to the left side of the right hand graphic, and the forms themselves look like the form on the right. Forms may have dates, numbers, check boxes, and small or large text fields. The phone screen is small, so you answer one field at a time before scrolling down to the next field. New forms can be sent to a phone via SMS, and if a blank form takes more than one SMS (only 160 characters per SMS) then it is automatically broken into 3-4 messages and reassembled once it reaches the phone. Once on the phone, the blank form can be filled out and sent back to the hub as many times as you want, and only the answers to the fields are sent back (not the lables etc. for each field). This means, for example, that a form could have 20-40 check boxes and 20 fields with short 1-2 digit number answers each, and the entire form would take just one text message to send. When a form is completed, it can be sent immediately if there is network, or it can be saved on the phone and sent later when network is available.
- Forms from hard to reach village clinics will be sent to the computer of the district level HMIS officer (hospital statistician), who will validate the data and may send a reminder text message to any H.S.A. who has not sent in their form on time. HMIS officers then upload form data to the Internet so that it is accessible in the Management Sciences for Health and IMCI offices in Lilongwe for anyone who has a username and password. The ultimate goal is to reduce reporting time from hard to reach clinics to Lilongwe office from 2 months or more to just 1-2 days. Note: Andreas from the audience asked “if an H.S.A. does not fill out their form, and you just remind them with a text message, is it possible that they would not take it seriously and just fill out inaccurate numbers? Wouldn’t it be better to follow up with them in person?” I’d say the answer is probably yes; whenever you can afford to follow up in person that is probably better. I don’t want to pretend like this technology is good for everything or that it should be used for every situation. But if the alternative is to have no data or to risk that data may be inaccurate, I would suggest that you tust your H.S.A enough to get what data you can and try to validate it as thoroughly as possible.
- After forms have been aggregated to the Internet, what will staff in Lilongwe see when they go to look at the data? At St. Gabriel’s we noticed the outreach team was often looking back and forth at the FrontlineSMS screen and these big paper maps, where they had placed push-pins to label health centers and community health workers. We thought it would be easier, more comprehensive and accurate to digitize this map, so we have been working with a Kenyan group named Ushahidi (www.ushahidi.com) to place text messages on maps.
- This is an example of an Ushahidi map. The stop stockouts team submitted SMS reports that were received by a FrontlineSMS hub and then placed on a map for aggregation and visualization online. The larger red dots represent areas with more reports, and you can see the reports more closely by zooming in. You can also view reports by category. For the Management Sciences for Health project, we aim to sort by form name as well as by location.
- In the coming months we hope to take advantage of increasing connectivity in Malawi. Expand to even more remote areas as mobile phone network improves. As the mobile phone network improves, we may also begin to access data (Internet) over the mobile phone network. Currently, this service is mainly only reliable around Lilongwe and Blantyre, but as it becomes more widespread, it will be useful because it is less expensive to transfer data this way than with SMS. We are working to translate our FrontlineForms tool to accommodate the Xforms data standard, so that our forms can be read by the OpenMRS/Baobab electronic data system. We are also keen to explore integration with DHIS 2.0, which is also being implemented in Malawi. We believe the ideal niche for FrontlineSMS:Medic is to serve the hard to reach areas - SMS hubs at district hospitals and health centers, and phones at hard to reach village clinics, all sharing information with Baobab and DHIS systems at the district and national level. Note: This slide was also removed from the presentation on February 4th Data Standards Meeting due to time constraints.
- I will be based in Malawi until early June, then will be in the U.S. for several months before returning to Malawi. I am more than happy to answer questions or strategize about health information in East Africa, either via email, phone, or in person. This presentation can be found and downloaded at: http://www.isaacholeman.org/2010/frontlinesms-malawis-ministry-of-health-meeting