USAID and Leapfrog Technology

 

As I’ve explained to Neil, I’m a PR person who’s primary job is to represent USAID and our partners and advocate for our continued existence.  I’m not a program expert.  So given my propensities, I’m first going to tell you broadly where USAID excels, then go into specifics about leapfrog technology, both where we are and where we need to go. 

 

USAID has been a world pioneer in using communications media, especially mass media, to change the health knowledge, attitudes, and practices of people.  For example, important health concepts like how to use oral rehydration therapy or the importance of family planning can be effectively communicated via radio in short messages; soap operas draw audiences for longer messages, repeated over time.

 

My agency also is very focused on improving the quality of care to increase access.  Eleven years ago, we launched a global initiative, Maximizing Access and Quality of Care, we call it MAQ because we are acronym obsessed, that was designed specifically to promote quality services, enhance providers’ capabilities, and remove barriers that can discourage clients from using services.  Much of our focus is on training health care providers to ensure they have the skills, products, and programs they need to deliver top notch health services. 

 

Now that I’ve attended to my job description, let me now tell you how we are using leapfrog technologies.  I have some program examples; I have some lessons learned; and I have some commitments for the future.

 

USAID increasingly are becoming persuaded that the use of low-cost, hand-held computers for our DHS surveys, for collection of medical information, and in improving quality of care by health personnel is not only viable, but something that needs stronger support.  This is forthcoming, and my colleagues back in Washington are increasingly adding this language to their vocabularies.  We are by and large luddites, so I’m very proud of them. 

We fund projects that make use of leapfrog technology in:

Computer-assisted personal interviewing is increasingly replacing paper-and-pencil questionnaires in face-to-face surveys.  It is a practical way of reducing data collection costs while increasing the accuracy of the data through programmed consistency checks and automated skip patterns.  Computerized systems also have been used to collect data when the information requested is of a sensitive nature.  Computerized interviews also eliminate the need for secondary data entry and cleaning, further enhancing data quality by removing keystroke errors. 

We have supported several empirical studies in developed countries to test whether computerized interviews provide greater reporting of sensitive behaviors.  To condense this body of research, these studies have generally found that CASI and audio-CASI provided increased reporting of intravenous drug use, multiple sexual partners, and unprotected sex.  What has emerged is that computerized administration of questionnaires related to sensitive behaviors increases the reporting of such behaviors and provides a more efficient and effective way to implement self-administered surveys.  However, in the developing world, survey researchers in developing countries have only recently begun to incorporate the use of CASI and audio-CASI technologies.  While this is not directly related to quality of care issues, it can be applicable, so I will share a few results with you. 

MEASURE DHS+ and MEASURE DHS projects

Since the late 1990s, the USAID-funded MEASURE project has been collecting geographic information for most DHS surveys using hand-held Global Positioning System (GPS) units. They collect latitude and longitude coordinates for the communities in which survey respondents live. Researchers can then use the lat/long locations to link the DHS to external datasets such as road networks, health facility locations, land use and land cover information, climate, rainfall, etc. 

 

They are currently piloting the use of hand-held computers (PDAs) equipped with GPS units to carry out the household listing and cluster mapping tasks that are completed at the beginning of the DHS surveys. They are piloting this to see whether they can improve the quality and increase the efficiency of the listing information that they normally collect. The computerized sketch maps will be used to send the survey teams back to the field, so that they can easily and quickly locate the households selected for the survey. Fieldwork planning can perhaps be improved as a result. Finally the detailed geographic information can be used for further analysis of the DHS data.

Population Council projects:

In Zimbabwe an evaluation was done to determine if women with little or no familiarity with computer technology could adapt to self-administered audio-CASI interviews. Some 220 women aged 18 to 50 across three educational groups (from primary education or less to university graduates) proved able to use the computer effectively; however, the ability to master the tasks of completing the survey varied by education, with the less educated encountering more problems.  However, in all categories, the women overwhelmingly preferred being interviewed with audio CASI. 

Another study of adolescents done by the Population Council, and again, because of the time limitations, I am providing a highly general overview (I have handouts with information on how to access these reports), showed that the technological challenges do not pose a major hurdle in implementing a field study using mobile computer equipment.  Moreover, adolescents generally had positive reactions to computers, and the difficulties of training respondents to use the equipment were minimal.

Management Sciences for Health are in the midst of implementing a PDA program in their Tanzania project. In 2002, the Tanzania Food and Drug Authority put forward a plan to structure the product and premises inspection programs.  Standard operating procedures and flow chart decision trees were created, which ordered the application of laws and regulations. Associated forms were developed to guide inspectors through the inspection processes.  There were successes: Inspections increased from 942 consignments in 2001 to 1,665 consignments in 2002 and premises inspections from 201 in 2001 to 887 in 2002. But because of the high number of forms returned, analysis of the data was very time consuming.  So in April 2003, they decided to incorporate PDAs and databsase into the inspection process.  From June to September of that year, TFDA and MSH worked with Sattelife to convert the existing inspection forms and SOPs into PDA compatible format.  By October, they had completed training and field testing, worked out the bugs, and launched the new system in November. The results?  Overall net inspector’s time savings was about 30 to 40 percent. 

Entry time of field data significantly reduced compared with manual entry of data.

·        Data entry confirmation time reduced by about 95 percent.

·        Monthly summary preparation time reduced by about 90 percent.

·        Rapid management access to all inspection data and reports.

·        Structured and regular updates of lists for inspectors.

BANGLADESH

USAID Washington and the local USAID office in Bangladesh fund many of the community health intervention projects at the Centre for Health in Population Research in Dhaka.  Cell phones were donated for the first outbreak investigation of the Dengue in Dhaka City two years ago.  Grameen temporarily donated cell phones so that the student teams that were trained by their epidemiologist, Dr. Yukiko Wagatsuma, could travel into communities for their surveys with a certain amount of safety and contact ability.  The city wards were geo-coded with hand-held GPS devices to map foci of the outbreaks.

In a Johns Hopkins Nutrition Project in Rangpur, Bangladesh is using hand-held computers in their work, including data entry and mapping technology for their very large study areas.  This JiVitA project hand held expert is Andre Hackman in the JHU Bloomberg School of Public Health, Department of International Health with Jon Sugimoto on site in Northern Bangladesh.  The people in our mission in Bangladesh urge you to contact them, as he believes we should learn from people on the ground who are doing this work, not just the theorists.

Learning Resource Centers.

The American International Health Alliance works to promote both immediate and long-term improvements in clinical care at individual, institutional, and systemic levels. Towards this end, they have established Learning Resource Centers to supply healthcare professionals with current information on t he most effective practices within their specialization, while helping these professionals build new programs rooted in evidence-based medicine.  LCRs are institution or community-based telecenters, which consist of at least one computer with internet access, a scanner, and a collection of health and medical databases.  IN addition to providing a direct link to current information sources, the LRCs also offer opportunities for education, communication, and collaboration within the partnership netwowrk, as well as with the international health community. 

This organization also manages the health care partnerships program in the Newly Independent States and Central and Eastern Europe under a cooperative agreement with USAID. As part of this program, they have established "Learning Resource Centers" at hospitals, clinics, and medical universities throughout the region.  While they have not routinely provided PDAs or mobile phones to partner institutions through this program, a couple of institutions have chosen to pursue the use of this technology with ftheir support.  One of these, in Uzhgorod, Ukraine, use their PDA for the following purposes:

 

(1) Capturing patient info, medication, etc

 

(2) Communications (e-mail and Internet access through an infrared link to a cell phone)

(3) Organizer, notes, text editors and spreadsheets

 

 

Research

The Pop Council has conducted operations research project in Honduras for the USAID supported program.  In this project, they developed simple self-calculating spreadsheets using HP handheld computers and Excel CE and tested their feasibility for monitoring, evaluating, and facilitating supervisor feedback to improve family planning services.  Although these instruments reflect Honduran FP norms, the coding for good quality care uses international norms (for example, that husband's permission is not required for certain services).  The computers and programs were also introduced to the Peru MOH/FP.

 

Since then, they have developed a number of similar computerized tools, including a post-abortion, maternity and child care tools.  Population Council has used the PAC tool in Mexico to assess improving PAC care, the child care tool in NGO clinics in Guatemala, and has only filed tested the non-computerized version of the maternity care tool in public clinics and hospitals in Vietnam.

 

In addition, the Population Council is using HP720 handhelds for data collection and immediate post-interview data cleaning in a large randomized controlled trial of community-based kangaroo mother care (a novel intervention which we recently successfully adapted from the standard hospital method.  They enter the data into an Access CE data base, and use Excel CE programs so the interviewers can review inconsistencies and correct them before they leave the household.  The handhelds are password protected as is the Access database, so confidentiality is maintained.  The data collection supervisors copy the data onto their handhelds and also on to a 32 MB storage card at the end of every day.  Each interviewer and supervisor has an extra battery, and each interview team an extra handheld computer.  The supervisor carries hard copies of the interviews in case of need, but as we are just beginning the baseline survey, they have not encountered this need.  The computers are recharged nightly in a central location.    So far, they have used the computerized system for the pilot study, and have found that Mitra and Associates, perhaps the most competent survey association in Bangladesh, has been pleased with their use.  Certainly, this system allowed us to analyze, complete and submit the publication of our pilot study within three months of its completion. 

 

 

Satellife

To prepare for this meeting, I also spoke at length with Holly Ladd, who, I understand, had been invited to present today but could not do so.  You missed a good session with her.  She is definitely the guru in this area.  Among the projects she has been involved with:

In order to test the feasibility and usefulness of using handheld computers to conduct surveys, SATELLIFE joined with the American Red Cross (ARC) in their Measles Initiative, which aims to vaccinate at-risk children across Africa. Paper surveys are normally used by the Red Cross to gather data, but they are time-consuming, plagued with errors in data collection and transcription, expensive, and inevitably followed by delays in the receipt
of a final report. A PDA-based public health survey was designed to target mothers and other caregivers gathered at immunization sites in Ghana in December 2001. Prior to the start of the campaign, 30 Ghanaian Red Cross volunteers trained to use the PDAs over two days. They readily adopted the technology, though some of them had never used a computer before. The volunteers subsequently completed over 2,400 questionnaires in just three days, throughout the Cape Coast region. Stored data were transferred rapidly from each handheld computer to a laptop computer, using the synchronizing software and cradle supplied with the PDA. Transfer of data into the database was accomplished with no errors. ARC were able to analyse the data and deliver a complete report to the Ministry of Health within hours. The speed and ease of collection and reporting were unprecedented.

She also distributed handheld computers to medical students in Kenya and practitioners in Uganda in Phase II. In addition to data collection tools, these units had country-specific HIV/AIDS, TB and malaria treatment guidelines and essential drug lists. Each unit also was loaded with two complete medical reference texts donated to us by Skyscape, a leading Massachusetts-based software company that specializes in mobile solutions for the medical community. SATELLIFE is currently collecting survey data and monitoring how the participants use the units and the information resources carried on them. A thorough evaluation is planned to examine the usefulness of both the technology and the content.

USAID has funded Holly’s efforts in Nepal for a series of household interviews about the Vitamin A campaign.  It was hugely successful and the training of the volunteers on PDAs was smooth and problem-free.  The PDAs proved very useful for such one-shot survey work, largely because the volunteers weren’t wed to a particular way to conduct these surveys, so didn’t need to change the way they worked.  I’ll talk about this issue later.

Handhelds: some of the lessons learned

For USAID, the major advantage of PDAs is the speed at which data collected in the field can be returned to policy makers for decision making. In addition, PDAs enable physicians and other health professionals to have constant access to up-to-date information in an environment where reference material is in short supply.

Our CAs experience offer insights into how these handhelds can work in the field. For example, hey wanted a battery as opposed to a rechargeable unit to eliminate concerns about electricity. They wanted an affordable unit.  And they wanted something that could make use of freeware options. 

The batteries posed exactly the challenge one would anticipate.  The need for recharging them meant they had to use rechargeable units, which solved one problem – the really lousy quality of batteries in many countries.  And because electricity was such an issue in many countries or areas, they have relied on cigarette lighters, figuring what was good enough for the popular cel phone would work for the Palm. In Uganda, they are going to introduce a solar recharger.  In more remote areas where there are neither land lines nor cel lines, this group is looking at readopting an old method of recharging a bicycle, but this is still in the works.  A company called Freeplay, based in South Africa, makes crank rechargers for cel phones, so they’re seeing if they can adapt this to Palms. 

As more and more people are finding ways to use their cel phones and keep them working, they are watching closely and hoping to apply some of the same principles to PDAs.

Another problem is loss of data.  When people lose their power, they lose their data.  So they quickly learned to send out all pieces with a backup card.  For instance, the Uganda Red Cross keep a backup card in their units at all times, then they back up that data at the end of the day.  The triple redundancy has kept loss down. In Tanzania, health care workers only use the back up card – they have two.  They use it all the time, then give it to their supervisor who gives back to them a fresh card.  The supervisor backs up the card in a central area, and the process begins again.

Overall, the units were great in the field for those gathering data and in regular use by physicians.

Training is everything, and for continued use, the training must be relevant.  What has worked best is to conduct training in two stages.  Train.  Hand out the units.  Let them “play” with the units for a couple of days, then train again.

In addition, the effectiveness of a management information system is only as good as the design of the system. Simply automating a poorly designed system only allows for increased poor results.

It also is important to understand that technology can expose the bottlenecks.  With people processing data more rapidly, it becomes necessary for other individuals to work more rapidly.  In one example, the bottleneck occurred at the MOH level and it proved necessary to retrain the data processor to enhance and speed up her work skills.

There also is the question of what to do with the information if the systems aren’t in place on the receiving end, so one must consider how this all fits in, not only work-wise, but at the societal level.  In one instance, a group didn’t want leapfrog technology because the clinic was the only leverage the community had for getting electricity.  If they deployed technology that skirted the need for electricity, they were afraid they’d get unconnected.

Lastly, a major issue has been how to get people to change their work behaviors so that they would incorporate PDAs into their everyday lives.  I know this is a challenge, because USAID has not been able to make this happen in Washington.  Understanding how people use information and how they personalize information has been the key here.  In Kenya, medical students at Moi Hospital were given, free of charge, PDAs to help them record their visits and all information.  However, they didn’t belong to the student to keep, they had to be turned back in at the end of the training.  And they couldn’t use them for personal reasons.  The students could tell the capacity of the machines, but couldn’t access it.  Which made them resentful, and which meant the technology didn’t get used.  Realizing they had to instill the habit in students of looking up information on their PDAs, they expanded the uses:   putting medical texts, allowing personal email, news, weather, sports.  In short, making it a useful tool throughout the day, and not just a once-a-month use to do their MIS form.  By helping people feel ownership, they changed how the students worked. 

HIV/AIDS and ARVs offer other opportunities. ARVs will require the need to track drugs, patients on drugs, etc.  These needs highlight the need for rapid transmission.  But technology can’t impact the lack of drugs in the country.  However, one the positive end, it can make people smarter about distribution as they do trend analyses.  Hopefully, this will eliminate the stock out issues that plague so many programs in the developing world.  Using bar codes, thumb prints, or smart cards can greatly enhance logistics.

Other possibilities for handheld computers include record keeping, database management, and communication for sustainable development in health and in other fields, such as agriculture and environmental health. This initial work demonstrates the viability and usefulness of a new technology in Africa. In turn, this may stimulate a new market and provide incentives to the corporate sector to develop relevant tools at an affordable price for African users.

Even with these challenges, USAID funded projects are using leapfrog technology in varying ways to improve health in the developing world.  They are the innovators, and they will drive our future direction.

 

Final Remarks

 

While this innovation is proving to be a highly useful tool, we also are aware that developing countries continue to be restrained by resources: there are not enough experts, not enough tech-literate health professionals, and not enough money to introduce leapfrog technology at every cost-effective point of application. We know the pattern and the diffusion are constrained by policies and institutional capacities in every country and they are constrained by lack of general understanding in the health field.

I don’t have solutions to all these constraints, but I can leave you with some key messages.

USAID will increasingly draw on the innovations of our CAs and their willingness to explore the creative uses of this technology so health professionals can have access to the most relevant information for decision-making and practice.

End

Because there were many questions about why these approaches, and not others, are undertaken by USAID, I am appending information about the agencies strategy for global health.  

USAID's Strategy for Global Health

The Bureau for Global Health focuses on global leadership, technical support to the field, and research and evaluation. The Bureau performs these functions by forging strong relationships with its partners, which include USAID field missions and regional bureaus, the NGO community, host governments, multilateral organizations, and other bilateral agencies.

Through their primary functions of global leadership, technical support to the field, and research and evaluation, USAID seeks to help stabilize world population and protect human health. Bureau for Global Health programs are directed at five broad objectives:

·        Reduction of unintended and mistimed pregnancies

·        Improvement of infant and child health and nutrition and reduction in infant and child mortality

·        Reduction in deaths and adverse health outcomes to women as a result of childbirth

·        Reduction of HIV transmission and the impact of the HIV/AIDS pandemic in developing countries

·        Reduction of the threat of infectious diseases of major public health importance

 

 

Information Resources:

 

Africa's New Communication Users - What do they use and why? Background about celphone use. http://www.balancingact-africa.com/news/back/balancing-act_147.html

 

DATA COLLECTION

Population Council: Consistency in the Reporting of Sexual Behavior Among Adolescent Girls in Kenya: A Comparison of Interviewing Methods by Paul C., Hewett, Barbara S. Mensch, and Annabel S. Erulkar (2003) http://www.popcouncil.org/pdfs/wp/182.pdf  Explores the consistency in reporting of sexual behavior in a household survey of adolescents aged 15-21 in the Kisumu district of Kenya.  They find that contrary to expectations, computer-assisted self-interviewing (ACASI) did not increase accuracy of response, even though it afforded greater privacy.  Instead, respondants were more likely to report sexual activity in face-to-face interviews.  However, there were many mitigating factors. 

 

The Feasibility of Computer-Assisted Survey Interviewing in Africa: Experience from Two Rural Districts in Kenya by Paul C. Hewett, Annabel S. Erulkar, and Barbara S. Mensch, (2003) http://www.popcouncil.org/pdfs/wp/168.pdf

Describes the experiences of carrying out a household-based study using computers and explores the technical challenges faced by the data collection teams.

 

Community-based kangaroo mother care adapted from the standard hospital method (Quasem I, Sloan NL, Chowdhury A, Ahmed S, Winikoff B, Chowdhury AMR. Adaptation of Kangaroo Mother Care for Community-Based Application.  Journal of Perinatology 2003; 23(8):646-51.)  

 

Other POP Council resources:

http://www.popcouncil.org/rhfp/sitanly.html

http://www.popcouncil.org/rhfp/palmtops.html

http://www.popcouncil.org/publications/momentum/momentum700_1.html

http://www.popcouncil.org/hrs/usermanual/Principles.html

http://www.popcouncil.org/publications/popbriefs/pb6(2)_6.html

https://www.popcouncil.org/hrs/hrs.html

 

The American International Health Alliance manage the health care partnerships program in the NIS and CEE under a cooperative agreement with USAID. As part of this program they have established "Learning Resource Centers" at hospitals, clinics, and medical universities throughout the region (see http://www.aiha.com/index.jsp?sid=1&id=1280&pid=4739 for more information about this program).  Their program in Uzhgorod, Ukraine, where PDAs are being used to capture patient info, medication, etc., they are using an application called Patient Tracker -- freeware, available for Palm OS and WinCE, see

http://www.handheldmed.com/prodmore.php?PRID=140&DETAIL=)

 

 

 

Contacts:

Arin Speed

Center for Pharmaceutical Management

Management Sciences for Health

4301 North Fairfax Drive

Arlington, VA 22203

USA

Email: [email protected]

Web: www.msh.org  

 

Mark Storey

Program Officer

American International Health Alliance (AIHA)

1212 New York Ave., NW  Suite 750

Washington, DC 20005

Mark Storey [email protected]

 

Nancy L. Sloan, Dr.P.H.

Senior Associate

Population Council

1 Dag Hammarskjold Plaza

New York, NY 10017 USA

phone (212) 3390601

fax (212) 7556052

[email protected]

 

Contacts for MEASURE DHS Projects

[email protected]

Livia Montana [email protected] 

 

 

Bangladesh:

You can learn more about this from the Director, Dr. David A. Sack, [email protected] and from Public Health Sciences Division Director, Dr. Abbas Bhuiyia, who can help you contact his computer expert and identify other USAID funded leapfrog technologies:  [email protected]  or head of IS at ICDDR,B Peter Thorpe [email protected]

Dr. Yukiko Wagatsuma can discuss the work with the city wards and can be reached at [email protected].

JiVitA project hand held expert is Andre Hackman in the JHU Bloomberg School of Public Health, Department of International Health with Jon Sugimoto on site in Northern Bangladesh.  Contact Jon at [email protected]  or the project leader, Alain Labrique [email protected].   Both of them are residing in Bangladesh.