FrontlineSMS takes on rural healthcare in Malawi

Today sees the official launch of the new version of FrontlineSMS. To celebrate, invited Josh Nesbit – a Senior in the Human Biology Program at Stanford University – to talk about its use in east Africa where he’s spending the best part of this summer introducing the system into a rural hospital in Malawi. You can read Josh’s Blog here

“St. Gabriel’s Hospital is no stranger to assaults on well-being spread by disease and illness. Located in Namitete, Malawi, St. Gabriel’s serves 250,000 rural Malawians spread throughout a catchment area one hundred miles in radius. With a national HIV prevalence rate of 15-20%, children orphaned by AIDS will represent as much as one tenth of the country’s population by 2010. With tuberculosis (TB), malaria, malnutrition and pneumonia ravaging immuno-compromised populations, the health system – including St. Gabriel’s Hospital – faces a disquieting burden. Malawi’s health challenges are compounded by its devastatingly low GDP per capita, by some measures the lowest in the world.

With just two doctors and a handful of clinical officers, St. Gabriel’s Hospital is strikingly understaffed. This perennial state of affairs explains the shift of primary healthcare in other, similar settings, to Community Health Workers (CHWs), trained for specified tasks. Through the hospital’s antiretroviral (ARV) treatment program – drug therapy for HIV/AIDS – over 600 volunteers have been recruited. These volunteers are spread throughout villages in the Hospital’s catchment area. Some CHWs are HIV and TB drug adherence monitors, while others accompany patients during long journeys (up to a hundred miles, often by foot) to the hospital.

A few of the more inspired volunteers record their activities in notebooks, and travel to the hospital to have their good work acknowledged. The vast majority, however, remain disconnected from hospital activities, interacting with hospital staff only to pick up their drugs. It’s not that they don’t want to play a legitimate role in a community health system – there is no communication to foster such a role.

Enter FrontlineSMS. The program, developed by Ken Banks and his team at, is the cornerstone of a new, text-based communications initiative at St. Gabriel’s Hospital. Funded by the Haas Center for Public Service at Stanford University and the Donald A. Strauss Foundation, I’m currently knee-deep in a pilot program.

FrontlineSMS is being used to connect the hospital with its CHWs, expanding the role of the volunteers. Drug adherence monitors are able to message the hospital, reporting how local patients are doing on their TB or HIV drug regimens. Home-Based Care volunteers are sent texts with names of patients that need to be traced, and their condition is reported. “People Living with HIV and AIDS” (PLWHA) Support Group leaders can use FrontlineSMS to communicate meeting times. Volunteers can be messaged before the hospital’s mobile testing and immunization teams arrive in their village, so they can mobilize the community. Essentially, FrontlineSMS has adopted the new role of coordinating a far-reaching community health network.

The hospital sees intense promise in the formidable duo of FrontlineSMS and the cell-phone-yielding health worker. The usefulness of a well-managed communications network is undeniable, particularly when the information is so vital. In the first hours of the pilot program, a deceased patient’s extra ARVs were secured, the Home-Based Care unit was alerted of ailing cancer patients, and a death was reported (saving the hospital a day-long motorbike trip to administer additional morphine).

Rural healthcare has found, in FrontlineSMS, a powerful protagonist”.

Mobiles in Africa: A Travellers Perspective

This essay was originally commissioned in April 2008 by Vodafone receiver, Vodafone’s “neutral space where pioneer thinkers challenge you to discuss exciting and future-oriented aspects of communications technologies”. All images taken from the kiwanja Mobile Gallery

It didn’t take us long to find it. After all, mobile phone masts aren’t that easy to hide, and Masindi is a tightly-knit, flat little west Ugandan town. After a few short minutes, driving past countless mobile phone dealerships, internet cafes and village phone operators, there it was. I was last in Masindi in 1998, not that long ago in the grand scheme of things, but a lifetime in the short history of the mobile phone. Back then this mast wasn’t there, and neither were any of the mobile phone shops, internet cafes and village phone operators. The only phone line out of town – if and when it was working – was courtesy of the local post office. Every couple of weeks we would drive here to collect our post from the Ugandan Wildlife Authority, post our letters, have a cold beer, buy a few ‘luxuries’ and occasionally attempt to phone home. No text messaging in those days.

Just as I had done ten years earlier, I sat in the Travellers Rest drinking coffee, watching Masindi life go by. Unfinished buildings littered the edge of town, a scene not unlike the last time I was there, except this time endless mobile advertising banners broke the view. In a bold marketing ploy the entire café was branded “Celtel red”, yet it was only just managing to compete with the “MTN yellow” across the road. People were busy in their shops, busy carrying goods, busy ferrying passengers on their bikes, and busy on their phones. The mobile revolution is here, there and everywhere for all to see. What has happened in Masindi is happening all over Africa, a continent which now boasts almost 300 million subscribers and a penetration rate fast approaching 30%.

And the beauty is that no-one expected it. Back in 2004 I co-authored one of the earlier reports on the potential of mobile phones in conservation and development work. Focused mainly on Africa and funded by the Vodafone Group Foundation, we wrote it at a time when most people believed that rural Africans on a couple of dollars a day would never be able to afford a phone, let alone the credit to keep it going. Of course, four years ago mobile phones were expensive, but in many places the rampant growth of second hand markets made affordable handsets available for the first time. Nothing is thrown away here. At the same time, getting new phones into the hands of the masses was a key goal of the GSM Association’s “Emerging Market Handset Initiative”, announced back in 2005, an objective which continues to this day with the handset manufacturers themselves, many of whom are working hard to develop sub-$20 phones for this very unique “bottom of the pyramid” market.

Understanding consumers in emerging markets – many of whom have very different requirements of a phone – has spurned the development of handsets with multiple phone books, phones marketed as torches and even handsets with no screen. If you think that most of the innovation is going on in the West, take a moment to look at what’s happening in India and Africa. Even operators are getting in on the act, providing services such as “Call Me”, which allows Vodacom subscribers in South Africa to send up to five messages per day, free of charge, requesting a call back from the receiver. Services such as these have emerged in response to consumer behaviour, users who would have previously “flashed” the person they wished to speak to by ringing their phone once and hanging up. “Call Me” formalises the process, helps minimise network traffic through fewer prematurely disconnected calls, and allows operators to add value by differentiating their service from rival operators. A lot of the research, often the catalyst for these new devices and services, is increasingly lead by fellow anthropologists Jonathan Donner at Microsoft Research and Jan Chipchase at Nokia, both of whom spend considerable amounts of their time studying mobile phone use in the field and, in Jan’s case, working his way through a fair number of bicycles in the process.

When it comes to mobile innovation, the gap between developed and developing countries is not much of a gap at all. Mobile innovation in the West, largely technology-lead, sits in contrast to that in the developing world where combating the geographic, economic and cultural constraints of users is considered a more sensible way to go. This explains the emergence of the torch phone, for users who live in areas with little or no regular light, or multiple phone books for users who share their phones with family members. On the heavyweight side, a plethora of financial applications have hit the streets, with Safaricom’s m-Pesa service getting by far the biggest press to date. Regularly used by hundreds of thousands of Kenyans, you often hear it described as the “Kenyan Debit Card”, allowing users to transfer money through their mobile phones to help out family and friends, or to buy and sell goods and services across the airwaves. For the tens of millions of Kenyans without bank accounts, m-Pesa represents both a revolution and a revelation. It is now being rolled out in other countries, with Afghanistan next on the list.

Innovation is not always as official or formalised as this, however. People in developing countries are rarely simple, passive recipients of a technology, and rarely wait for outsiders to provide solutions to their problems. The entrepreneurial spirit is alive and well, evident by the masses of thriving small businesses you find on the street corners of every village, town and city. Last summer, in “A Review of The Postal and Telecommunications Sector: June 2006 to June 2007”, the Executive Director of the Uganda Communications Commission presented some quite incredible statistics. Official employment in Uganda’s ICT industry – dominated by telecommunications workers – sat at a little over 6,000. Informal, unofficial workers not directly employed, but who were making a living on the back of the industry, was estimated at a whopping 350,000. Amazing as it may be, Uganda is no exception. This is happening all over the African continent.

These ‘informal’ businesses come in all shapes and sizes, as do the kiosks many of them operate from, manufactured using anything from wood to metal sheeting, or made up of simple tables and plastic chairs. Mobile phone repair shops, often equipped with just a handful of basic (and frighteningly large!) tools, have sprung up to help owners squeeze the maximum life out of their devices, many being used in some of the harshest conditions imaginable. Mobile phones are attached to bikes (two and three wheelers), and even boats, and taken to where the business is. In Uganda these bikes, known locally as boda boda’s, are hooked up with spare batteries and desktop mobile devices to create what are affectionately known as “Bodafones”. I met the owner of one on Kampala Road last summer, and got talking to him through the universally accepted language of English Premier League football. He also accurately predicted the result of the Liverpool match later that day – I should have got his number.

In “Mobile Telephony: Leveraging Strengths and Opportunities for Socio- Economic Transformation in Nigeria”, Christiana Charles-Iyoha sheds some fascinating light on the barriers to mobile ownership among Nigerian market traders. Erratic power supply, and difficulty charging, came top with a staggering 87%. Of course, Nigerians are not alone with this problem, and entrepreneurs are coming up with ingenious methods of meeting this crucial consumer need. Today, in some rural areas, users are able to charge their phones from a car battery which is taken to the nearest town, charged up and dragged back. In more urban areas with better mains supply, charging kiosks have sprung up allowing users to recharge their phones while they wait. Soon, with the continuing drop in the cost of solar chargers, many users will be able to do what I did last weekend down my local village green, and charge their phones using the most plentiful renewable energy source available – the sun (yes, we do occasionally get some in England). Interestingly, the total cost of this entire set up came to just over $40 – $22 for the ZTE handset (as being sold by MTN in Uganda), and $20 for the solar panel. Suddenly, with solar, there is light at the end of the charging tunnel.

Any discussion on mobile telephony, developing countries and economic opportunity would not be complete without a mention of Village Phone, Grameen’s pioneering work in Bangladesh which has recently taken root in Africa. A number of competing Village Phone schemes have since sprung up, providing business opportunities to mostly women, usually in rural areas, who borrow a small amount of money to purchase a phone. Members of the community, or passers-by, pay a small fee to make a call, or send a text message. Some of these schemes use desktop-style phones, which many owners prefer because of their ruggedness and the fact they are less likely to go walkabout. Culturally, bigger is also generally seen as better, a view somewhat at odds with how we feel about mobile devices in the Western world.

Other schemes use standard mobile phones, such as Nokia’s entry-level 1100 (for a while the best selling phone on the planet), while Motorola developed their own “pay phone” specifically for the job, allowing operators to enter the number of units to be used before handing the phone over to the caller. This helped ensure customers didn’t talk for longer than they’d paid for, and negated the earlier practice of operators having to rudely grab phones back with their clients in mid-sentence, or having to smack their hands down on the hang-up button of a desk phone before they’d had the chance to say goodbye.

In many places I’ve seen handsets used primarily as phone books, torches or even once as a method of keeping track of bad debts, but despite some ingenious offline applications mobiles are not much use as a communications device without a signal. On the whole, operators are doing what they can, but with geographically disbursed populations, often with little disposable income, it’s sometimes difficult to make a business case for increasing coverage to an area with a minimal, and scattered, population. But where networks do exist, operators in East Africa are blazing a trial, doing something unheard of in Europe and in many other parts of the world. We’re talking roaming, and we’re talking “one network”.

Celtel, MTN and Vodacom are just three of a growing band of African operators tearing down national boundaries to allow their customers seamless mobility as they travel from country-to-country. Advertising boards are scattered everywhere. “One SIM card. 6 countries” proclaims Celtel. “Travel with your Vodacom SIMcard and enjoy Vodacom tariff in Kenya and Uganda” boasts Vodacom. The speed of change in the mobile industry – more so it seems in developing countries – continues unabated. Again, the telecommunications gap between the so-called developed and developing countries looks a little blurred. Travelling across central Africa with a single SIM, on a single tariff, is a business person’s dream.

You may not see a Bodafone on your street anytime soon, but you may see a single European-wide network.

And if you do, just remember where it happened first…