SMS-powered rural healthcare in-a-box

A few months ago Josh Nesbit, a Senior in the Human Biology Program at Stanford University, travelled to east Africa where he spent the best part of his summer introducing FrontlineSMS into a rural hospital in Malawi.

St. Gabriel’s Hospital, where Josh worked, is located in Namitete. It 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, and with just two doctors and a handful of clinical officers, St. Gabriel’s Hospital is also strikingly understaffed.

With woefully inadequate communications exacerbating the problem, Josh – with the help of the Haas Center for Public Service at Stanford University and the Donald A. Strauss Foundation – implemented kiwanja‘s FrontlineSMS software to connect the hospital with its community health workers (CHW). Now, 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. The “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. According to Josh, FrontlineSMS has essentially 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).

Since returning to Stanford, Josh has continued his work, speaking at a number of conferences and workshops and producing a user manual – “Building an SMS Network into a Rural Healthcare System” (available here as a PDF, 7Mb). According to Josh, the guide “provides an inexpensive way to create an SMS communications network to enable healthcare field workers as they serve communities and their patients”.

Not only has FrontlineSMS enabled a significant improvement in healthcare delivery for St. Gabriel’s, the project is infinitely scalable and replicable. Coming in at just $2000, Josh has clearly demonstrated what is possible with just three basic ingredients – a single laptop, one hundred recycled mobile phones, and local ownership and engagement. Now, with his step-by-step user guide and the minimum of investment in time and money, rural hospitals the developing world over can easily implement their own SMS communications network.

Cambodian farmers turn to their phones

At the University of Canberra, Senior Research Fellow Dr Robert Fitzgerald has been evaluating FrontlineSMS as a replacement for a commercial application previously implemented in their Cambodia Crop Production and Marketing Project (CCPMP). Since 2006, Robert and his team have been developing an SMS-based market information service for maize and soybean farmers and traders in western Cambodia.

CCPMP research had already highlighted poor communications between the different levels of the supply chain as a major challenge to the agriculture sector in the region. According to Robert, “We explored various options for the development of an improved marketing communication system and proposed to local stakeholders the development of an Electronic Marketing Communication System (EMCS) based on the use of SMS technology. We undertook a pilot project in which daily grain market information was collected by the Ministry of Commerce and entered into a database that was accessible by mobile phone in Cambodia using SMS”.

The pilot project proved highly successful and its impact stimulated further work in a follow-up project funded by the Australian Centre for International Agricultural Research (ACIAR). It was at this point that Robert and his team began to explore alternative messaging systems.

“One of the most encouraging aspects of our early work was the excitement generated amongst farmers, traders, ministry officials, silo owners and potential development partners. The SMS concept was very appealing but we faced a real challenge – we wanted to use this excitement to move from a trial project to a fully fledged operating model but we needed a software application that would ensure the long term sustainability of community-based communication systems. Because the project is working with two NGOs based in western Cambodia, it was imperative that we implemented a cost-effective solution that could be managed by local staff. As it turned out, FrontlineSMS had it all. Not only is it open source but it is simple to install and maintain, and has more functionality than our previous software, all combined with a much better user-friendly interface”.

Since launch of the latest version earlier this June, Dr. Fitzgerald has been testing FrontlineSMS at the University of Canberra along with a Cambodian Phd student, Nou Keosothea, who will be working with him to conduct in-country trials over the next few weeks.

Our plan is to install two FrontlineSMS systems in the Pailin and Samlaut regions of western Cambodia. Once these are installed we will conduct a series of stakeholder workshops to better understand the communication aspects of the maize and soybean production and marketing supply chain. Price, weather updates, handy hints will all figure on these systems in addition to standard SMS-based communications

Watch this space for further updates as the project moves forward, and details of a number of other agriculture-based FrontlineSMS implementations being planned by NGOs around the world.

Mobile telephony and the entrepreneur

This article – “Mobile telephony and the entrepreneur: An African perspective” – was originally written for the autumn edition of Microfinance Insights magazine. A copy of the original article is available as a PDF here

Whenever the words “Africa” and “economic development” meet – which is often – it’s usually in the context of external, foreign aid and large, multilateral development efforts. Large numbers and global donor agencies do, after all, have a habit of stealing the headlines. You’d be forgiven for thinking that little else was happening.

But you’d be wrong.

With penetration rates in excess of 30%, and handset sales among the highest in the world, Sub-Saharan Africa is witnessing a new kind of home grown, mobile-driven economic development. The numbers may not be that big – yet – but the impact on the ground is obvious and the difference it is making to people’s lives clear. Farmers are now able to access market information through their phones, increasing income in some cases by up to 40%. Casual labourers are able to advertise their services, allowing them to take on more work and avoid down-time waiting on street corners for work to come their way. Unemployed youth can get job vacancies on their phones, alerting them when work becomes available. And, for the first time, the un-banked can transfer money to relatives, or make payments for goods and services, through their phones.

Their impact is not restricted to economic empowerment, either. Mobile phones are also able to provide health information and advice, remind people when to take their medicine, and allow citizens to engage more actively in civil society by monitoring elections and helping keep governments accountable. Others can get wildlife early warnings, mitigating against livelihood- and life-threatening human-elephant conflict. It turns out that mobile phones can be useful for much more than just ordering pizza, looking up the football scores or arranging a Friday night out.

The impact, and uses of, mobile technology in the developing world is nothing short of staggering. What’s more, it has spurned the growth of a whole new informal sector, empowering local entrepreneurs and businesspeople the continent-over. With immense value placed on owning a phone, there’s no shortage of opportunities for people to make a little money on the way.

In “Mobile Telephony: Leveraging Strengths and Opportunities for Socio-Economic Transformation in Nigeria”, Christiana Charles-Iyoha sheds some light on the value Nigerians placed on their mobile phones, many describing losing them as literally a matter of life or death for their businesses. At the same time, many – not only in Nigeria but also many other parts of Sub-Saharan Africa – have been quick to exploit the numerous opportunities that this explosion in ownership brings.

Anyone who’s travelled to an African country in the past couple of years would not have failed to notice women selling airtime on the streets, children dodging cars at main junctions selling chargers and phone covers, street vendors making a living charging people’s phones, and mobile phone repair shops helping people squeeze one last drop of life from their old phones. There is also a thriving second-hand market, with stalls selling all manner of new and recycled handsets. Entrepreneurs are even building their own mobile-mobile services, strapping phones and spare batteries to the front of bikes and travelling to where the business is.

In a now much-cited 2005 study, London Business School economist Leonard Waverman concluded that an extra ten mobile phones per hundred people in a ‘typical developing country’ leads to an additional 0.59 percentage points of growth in GDP per person. From a government perspective, taxes and revenue generated from an insatiable demand for communications no doubt fuels a large part of this growth, but there’s also little doubt a significant amount also comes from a growing, and increasingly efficient informal sector. At the bottom of the pyramid (BOP), where micro-loans of just a few dollars are a proven catalyst in helping people work their own way out of poverty, we have a technology which has the clear potential to do the same.

Of course, more phones in more hands also presents opportunities for the microfinance (MFI) sector, many of whom seek to improve the lives of those same people in or around the bottom of the pyramid (BOP). Mobile technology has already been embraced by organisations such as Grameen, with their now-much duplicated Village Phone programme, but mobile phones also present organisational opportunities through improved communications with field staff, and options to electronically capture data from the field. MFI’s are already utilising text message (SMS) technology to communicate with customers, using software such as FrontlineSMS – which turns a computer and attached mobile phone into a central SMS communications hub – to run surveys and collect information. In many remote areas where keeping in touch with borrowers, or collecting financial data, is a challenge, the humble SMS is opening up a raft of new opportunities. Grameen Village Phone in Kampala, Uganda, a user of FrontlineSMS, comments:

We use it to automate communication with our village phone operator (VPO) channel. It really makes our lives easier by giving us a clear record of what’s been sent and responded to that can be reproduced and reused elsewhere. It also helps us promote a culture of SMS use for communications

As more and more people become connected, future studies of Sub-Saharan Africa and its economic potential will find it harder and harder to ignore the growing influence of mobile technology, and the power and spirit of African entrepreneurship – and grassroots NGOs – to capitalise on it. There’s little doubt that this spirit has always been there, but perhaps it’s just taken mobile technology to create an environment in which much of it can thrive.

Call to arms: Meeting our Clinton Commitment

It’s not every day you get to glance around the room and see the likes of Bono, Al Gore, Mohammed Ali, Tony and Cherie Blair, Olusegun Obasanjo, John McCain, Bill Gates, the Queen of Jordan and Bill Clinton. I’m just back from an incredible week where I did just that, thanks to a complimentary invitation to this year’s Clinton Global Initiative (CGi) annual meeting in New York.

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Despite the line-up there wasn’t too much time to get star-struck. Condition of membership – worth a whopping $20,000 – is that new CGi members make a ‘commitment’, outlining an idea which, when implemented, is expected to “impact on the lives of hundreds of millions of people around the world over the next ten years”. kiwanja’s commitment might not reach such dizzy heights, but it was deemed significant enough to be announced live on-stage during the ‘Poverty and Information’ workshop on Friday.

kiwanja’s commitment – the FrontlineSMS Ambassadors Programme – seeks to increase the scale of FrontlineSMS use among the global grassroots NGO community. By the end of 2010 our commitment is to reach an additional 5,000 users through a combination of:

  • Identifying leading international organisations working in key areas of education, energy and climate change, global health and healthcare delivery, and poverty alleviation

  • Training Ambassadors within each organisation how to use FrontlineSMS and how to leverage the software’s rapid prototyping capabilities in order to meet needs and outcomes

  • Charging individual Ambassadors within each organisation with the promotion and implementation of FrontlineSMS use within their organisations and organisational area of influence

  • Recruiting teams of volunteer Ambassadors from civil society

  • Enabling individual Ambassadors to report use, constituency impacts and measurable outcomes derived through FrontlineSMS implementation

  • The development of a FrontlineSMS Ambassadors website and resource centre

The commitment is due to start in January 2009. Between now and then we’re going to need help in two critical areas. If you’re a web developer interested in volunteering a little time to help us get a site together, please get in touch. Or, if you have project management skills and are interested in helping plan and co-ordinate this exciting new Programme, drop me a line. Alternatively, if you know anyone else who might be interested in helping out in either of these areas, please let them know. If you’re new to FrontlineSMS and want to find out a little more, check out this recent Blog post, or check out the project website.

Help empower the grassroots NGO community, and help take FrontlineSMS to new heights.

Make your own commitment to help us reach ours.