global health innovation conference PMTCT mobile mhealth

1. mHealth: Scale Up of Mobile in PMTCT Program
technology isn’t the barrier to scale up
• Bobby Jefferson, Director Health Informatics, Futures Group
• Principal Investigator – Health Information Systems Grant Kenya
• Partners in AIDS Care and Treatment, University of Maryland Institute of Human Virology
• Tanzania HIV AIDS Relief Program 1
• Tanzania Orphans and Most Vulnerable Children (MVC) MIS

2. Outline
• Description
– Low Resource Environment
• Approach
– Low cost, appropriate technology
• Solutions
• Sharing Scale Up Lessons

3. Environment
423 ART Hospital Facilities
770 PMTCT - Antenatal Care (ANC)
Low Resource
Rural, remote, mission hospitals “serving poorest of poor” and Ministry of
Health (MOH) facilities
• Intermittent power,
• Lack of trained IT staff,
• Lack internet,
• Sparse mobile coverage

5. Photo credits: Brian and Angie Savage

6. Low Resource Environment
Nurses, Clinicians, Adherence Counselors, need health data, M&E
program data in knowledge repository
• Lack of referrals, or linkage between HIV, PMTCT, TB, or to existing
technology systems
• Cost effectiveness and sustainability -- no funds for proprietary
licenses, or yearly maintenance fees

7. Off Grid Technology: Address
Approach
Intermittent Power
How to Give Presentations or
IT Training
in
Rural Clinics When
Power or Generator is Offline
?
to address power

8. Off Grid Technology: Address
Approach
Intermittent Power
Battery Operated
Projector
to address power

9. Off Grid Technology: Address
Approach
Intermittent Power

10. Off Grid Technology: Address
Approach
Intermittent Power

11. Off Grid Technology: Address
Approach
Intermittent Power

12. Off Grid Technology: Address
Approach
Intermittent Power
How to Print In Rural Clinic When
Power or Generator is Offline
?
to address power

13. Off Grid Technology: Address
Approach
Intermittent Power
ZINK – Zero Ink
Portal Printers
*use to QR code for
Patient ID
to address power

14. Technology
Approach

15. Off Grid Technology: Address
Approach
Intermittent Power
How to Power Netbook Computer
in Rural Clinic When
Power or Generator is Offline
?
to address power

16. Technology
Approach
Samsung Solar
Netbook PC - NC215
Intel Atom N570 Processor 1.3 GHz
1 GB DDR3 Memory Module
10’ LED Backlit LCD Screen
250GB 5400 rpm Sata Hard Disk
802.11bg/n Wi-Fi
10/100 Ethernet Port
0.3 Mega Pixel Web Camera
802.11 b/g/n Wireless LAN
Bluetooth V3.0
Headphone Jack,
4-in-1 (SD, SDHC, SDXC, MMC) Multi
Card Reader
3 USB 2.0 Ports & VGA Port out
3 W Stereo Speaker (1.5 W x 2)
Dimensions : 10.20″ (W) x 7.07″ (D)
x 0.85″ ~ 1.33″ (H)
Warranty : 1 Year Warranty

17. 18

20. Photo credits: Brian and Angie Savage

21. Distance from Time spent to
Facility Name District Facility to District Deliver PMTCT Bus Fare (Tsh)
Tanzania (KM) Report (Hrs)
MWANZA Region
NYAMAGANA DISTRICT
Mwamashimba Health Centre Kwimba 50 1.30hrs 10000
Malya Health Centre Kwimba 25 1hr 5000
Kikubiji Dispensary Kwimba 102 4hrs 20000
Kiliwi Dispensary Kwimba 100 4hrs 20000
KWIMBA DISTRICT
Nyakalilo Health Center Sengerema 46 2 HRS 8000
Mwangika Health Centre Sengerema 98 4 HRS 10000
Sengerema Health Centre Sengerema 10 20MIN 3000
SENGEREMA DISTRICT
Kharumwa Health Centre Geita 115 3HRS 20000
Nzera Health Centre Geita 48 2HRS 8000
Katoro Health Centre Geita 50 45MIN 6000
Nkome Dispensary Geita 80 2HRS 6000
Nyang'hwale Health Center Geita 85 2HRS 7000
Kasamwa Health Centre Geita 25 30MIN 4000
Bukori Health Centre Geita 60 1:30HRS 6000

22. Tanzania Environment
• staff Gender 89% female
• 100% posses mobile phone
• 71% used SMS on mobile phone
• Predominately Swahili speakers and readers

27. 28

28. IQSMS – Free software
 Report formatting  Data Type Validation
 Data validation  Report Duplication
Check
PMTCT MONTHLY REPORT
Jan-10
Paper Report SMS
PMTCT Antenatal Clinic (ANC) Monthly Summary
Form
LPTF 1
All women attending ANC for the
given report period
ANC 01. New ANC clients this month 1188
ANC 02. Previously known to be HIV positive 17
ANC 03. Total number tasted 574
ANC 04. Number of new client had HIV test at ANC 277
ANC 05. Tested HIV-Positive 37
ANC 06. Post-test counseled for positive and negative 574
ANC 07. Number of partners tested for HIV 16
ANC 08. Tested HIV-Positive 4

30. IQSMS Reporting
• IQSMS software,
PMTCT Report
Immediate Data Quality Alert
Pass or Fail

31. PMTCT Report
Data Quality Checks
District Office

32. Reports and Analytics

33. Query Database Using SMS From Mobile Phone
Bugando Clinic – Site 1
How many new antenatal clients this month?
How many were tested for HIV?
How many tested Positive ?
SMS Query: R1, M1, Site 1

34. Query Database Using SMS From Mobile Phone
SMS Query: 4679, 2561, 181

35. NUMBER OF CLIENT HAD HIV TEST AT ANC

37. Benefits
Submission via low cost mobile phones in the field
IQSMS project takes advantage of mobile phones already owned by health worker. By using a
familiar device, training requirements are similar to paper based training
Low cost of SMS submission ($0.04 per SMS)
Fuel and Transport cost savings in staff travel and reliable data submission
Health Care Workers no longer required physically to transport paper reports or fax PMTCT
reports to central project offices.
PMTCT Data can be made accessible to a wider audience (local, district, region, levels
Health facilities interested to know how their statistics compare with others in their districts
District officers want to receive aggregate report via SMS, email and
send queries to IQSMS database

38. Distance from Time spent to
Facility Name District Facility to District Deliver PMTCT Bus Fare (Tsh)
Tanzania (KM) Report (Hrs)
MWANZA Region
NYAMAGANA DISTRICT 15 Min Avg
Mwamashimba Health Centre Kwimba 50  
Malya Health Centre Kwimba 25  
Kikubiji Dispensary Kwimba 102  
Kiliwi Dispensary Kwimba 100  
KWIMBA DISTRICT  
Nyakalilo Health Center Sengerema 46  
Mwangika Health Centre Sengerema 98  
Sengerema Health Centre Sengerema 10  
SENGEREMA DISTRICT  
Kharumwa Health Centre Geita 115  
Nzera Health Centre Geita 48  
Katoro Health Centre Geita 50  
Nkome Dispensary Geita 80  
Nyang'hwale Health Center Geita 85  

39. Number of PMTCT Sites Reporting Using Mobile IQSMS
# of
Sites
# of Months

40. technology isn’t the barrier to scale up
# of
Sites
# of Months

41. technology isn’t the barrier to scale up
• After early adopters, health care workers not keen sending message
unless they have free airtime and toll free number available from their
mobile telecom provider ; we increase use by 50% when toll free is
available
• They wanted direct feedback from district coordinator verifying he
received their monthly report
• The older staff have more difficulty
using mobile for messaging and
reporting;

42. technology isn’t the barrier to scale up
• Staff in rural areas want their SMS messages in Swahili or local
language; Detailed instructions in Swahili to how to do reporting and
use phones for reporting
• Worker receive per diem for transports costs to bring their list and
reports district offices, losing out in reimbursement was not issue
• (25% share phone vs. Own)

43.  Instruction on
 Any problems with
Swahili critical to
small buttons on the
using IQSMS
phone?
 Response Freq %
 Response Freq %
 No 6 17.14
 No 30 85.71
 Yes 29 82.86
 Yes 5 14.29
 Total 35 100
 Total 35 100
• Reasons For Not Sending Monthly Report
– Majority said they don’t understand English
language
– Need message understandable in Swahili language

44. IQSMS Instructions in Swahili

45.  Barriers to implementing • Anything that can be
mobile phone reporting for improved on report
submitting all four reports submission to make
each month report to be on time
 Mobile Network Problem/failure • Response Freq %
 Server don’t respond on time • No 14 40.00
 Report type is hard • Yes 21 60.00
 It have been found that free • Total 35 100
Airtime is critical for scale up

46. technology isn’t the barrier to scale up
# of
Sites
# of Months

47. technology isn’t the barrier to scale up
• When PMTCT staff submits SMS report that fails validation
more than three (3) times; there is likely an issue with
understanding the indicators;
• We use data to target training on indicators to specific staff
• We still travel for
data quality audit (DQA) to
verify the reported values
against the register

48. technology isn’t the barrier to scale up
• Delay in Reporting times for PMTCT reports to district level
office went from 1-2 months to 30 minutes
• It takes on average only 15 minutes a month to submit all four
reports

49. M&E Electronic Reporting System
Solar Power Cell phones
PDA device
Ms Access Database
Excel
PMTCT MONTHLY REPORT
PMTCT Antenatal Clinic (ANC) Monthly
Excel Only Summary Form Web Internet
118 Desktop
ANC 01. New ANC clients this month 8
ANC 02. Previously known to be HIV
positive 17
ANC 03. Total number tasted 574
ANC 04. Number of new client had HIV test
at ANC 277
ANC 05. Tested HIV-Positive 37
ANC 06. Post-test counseled for positive
and negative 574
ANC 07. Number of partners tested for HIV 16
ANC 08. Tested HIV-Positive 4

50. Thank you
we predict the trends that will affect a
country’s stability and growth. we see
connections between disparate data points
that others miss— allowing us to uncover
the real barriers to well-being and discover
innovative solutions for a better world.