ICTworks by Inveneo

The first SMS, or “text” message, was sent over Vodafone’s network in December 1992. By most accounts, it read simply “Merry Christmas.” Using just fifteen of the permitted 160 characters, it was an appropriately succinct beginning to what is today by far the most widely used data service worldwide. By one estimate as many as 7 trillion SMS messages will be sent globally in 2011.

Smart Connect sensor

SMS’s reach and reliability, combined with its popularity among users, make it particularly attractive to those working on applications for the developing world, where Internet and smart phones are not yet widely available or affordable.

Open source SMS messaging platforms – RapidSMS, FrontlineSMS and others – and rapidly falling prices are fueling an SMS innovation explosion and fostering new thinking about how SMS can be leveraged for non-mobile applications.

Enter Smart Connect, a “communication appliance” developed by PATH and Inveneo which uses SMS to improve the reliability and performance of one of the most important systems in all of global health: the medical “cold chain.” First, though, a little bit on why the cold chain matters.

The Cold Chain

Few if any interventions compare with vaccination as a way to improve human health.

Famously, in the decade from 1967 to 1977, the World Health Organization (WHO) lead a global vaccination campaign against smallpox and, in 1979, officially declared that the disease had been eradicated. The Polio vaccine has come close to this mark, reducing the global incidence of this scourge by over 99% worldwide, and new vaccines for Malaria, HIV and more obscure diseases are in the works.

All told, the WHO estimates that, in 2003 alone, global immunization initiatives saved 2 million lives and UNICEF concludes that by 2015, immunization could be preventing 4 to 5 million child deaths each year.

Yet none of this would have been possible without the cold chain: the logistical processes and refrigeration systems that keep vaccines within strict temperature parameters from manufacture through administration. But with over 200,000 vaccine refrigerators in use in the developing world alone (according to PATH), most of them in harsh and remote environments, keeping the cold chain up and running is a major challenge.

Smart Connect

We developed the Smart Connect device to confront communication barriers and address the cold chain challenge by bringing a “digital dial tone” to remote health posts in the developing world.

Smart Connect device at Pacayita Health Post

We started in Nicaragua. During our research we visited rural health clinics in places like Yolaina, El Serrano, and La Fonseca bordering the remote Caribbean lowlands and Pueblo Nuevo, Las Cruces, and Zompopera in the Central Highlands. Each clinic serves a population of about 1,000 people with a staff of one to three.

During visits to these remote posts, we learned that it often takes many hours of travel by foot, horse or bus to reach the nearest town. As a result, health workers face long delays in picking up diagnostic test results and submitting reports. Also, problems such as running out of supplies or trouble with equipment go unreported.

It turns out that much of the necessary communication requires just a small amount of data. For example, a nurse in Nicaragua said she would like to know when the clinic lost power, so that she could check the vaccines, and she would like to know when pay was available so she could plan her visit to town. Based on these and other examples, we determined that SMS messages could be used by Smart Connect to send information.

In Nicaragua, we also discovered that – even though cell phones were widespread – health care workers would not consistently have cell phones. Cell phone coverage is often marginal – so some phones would work and others wouldn’t, or one had to find a very special place to stand to make a call. With most cell phone users relying on prepaid usage, it is common to have phones run out of credit.

We decided to make Smart Connect a facility based device. Even though it has many parts in common with a cell phone, it is constructed to be secured in place. We did this to improve security of the device, to ensure that the device was associated with the health facility, to allow it to connect with external sensors and to make it possible to connect to an external antenna for improved reception.

One of the first applications for Smart Connect is temperature monitoring of vaccine refrigerators. Refrigerators which regularly drop below freezing are quite common – so it is important to bring these to the attention of cold chain managers. Temporary power disruptions and breakdowns are also a problem since they lead to vaccines getting too hot.

Previously, refrigerator temperatures were tracked and recorded by hand with long delays in collecting the records. Now Smart Connect records the refrigerator temperature and sends out alert messages when there is a problem. Messages are sent to a web site and then automatically relayed to service technicians. A daily summary of refrigerator temperatures is also sent to the web site so that the manager can understand how well the equipment is functioning.

Beyond temperature monitoring, Smart Connect has the capacity to run a range of additional applications. For example, the Smart Connect deployment in Vietnam includes an application to track the use of vaccines so that that “stock outs” can be avoided. In the future, we plan for Smart Connect to be used with a bar code scanner to be able to read tags on vaccines when they arrive, and a printer to be able to provide receipts of test results to patients.

With Smart Connect we have seen that a small amount of communication delivered by SMS can have a big impact. By “thinking outside of the phone” we have created a custom communication device that meets the specific needs of rural health facilities and improves healthcare services in communities in Nicaragua, Vietnam and beyond.

This was first published as Thinking outside the phone by National Geographic

Closing the access gap with low-cost broadband service delivery models

Just 9.6% of the total population in Africa has access to the Internet. This is less than 1/5th and 1/6th of the rate in the Americas and Europe, respectively. But this statistic does not convey the real situation in the world’s poorest countries. Of Africa’s 48 sub-­Saharan countries, 29 (60%) have total Internet usage rates (at any speed) of less than 3%, and 15 (31%) show less than 1%. Broadband access rates are far lower still.

Thus, while wireless broadband has exploded in much of the world, as the ITU’s 2009 report points out, there remains “a dramatic broadband divide, with very few fixed broadband subscribers or mobile broadband subscriptions in Africa.”

Inveneo believes that closing the broadband gap will require new, collaborative and low-cost broadband service delivery models. Moreover, we believe that the essential components of such a model already exist; what’s needed is a well-conceived and coordinated effort to bring them together in a functioning service delivery framework.

In the Accelerating Broadband to the First Mile white paper, Inveneo and our partners are working to define and deploy a novel, locally sustainable wireless broadband delivery model, starting in Haiti.

The Inveneo­-led Haiti Rural Broadband (HRB) initiative is a collaborative program seeking to catalyze sustainable broadband access in underserved parts of Haiti. The program is founded on the idea that dramatic capital and operating cost savings can be realized through the use of ultra-low-cost wireless technologies, an emphasis on building local IT capacity to deploy and support broadband infrastructure and new approaches to cooperative network ownership and management.

HRB’s primary short-term objective is to bring affordable, reliable and sustainable broadband access to 6 regions and 20 currently un-served population centers across Haiti. The longer-term goal is to explore how the HRB model can be replicated in similarly rural and low resource areas across the developing world.

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A few weeks back I had the privilege of serving as one of 4 judges for the business plan competition that is the culmination of Assistant Professor Tapan Parikh's graduate course, "ICT for Social Enterprise", at UC Berkeley's School of Information Sciences.

I was introduced to the course and the competition last year, when I also judged, and from what I saw this year all I can say is that if I were going back to school (a perennial fantasy of mine), and if I had any real tech chops, I'd want to go to Cal in the iSchool. Full disclosure, I was Bear as an undergrad so am a bit biased.

This year we evaluated 5 projects, each of which puts ICTs at the core of an innovative Social Enterprise business model. Though each pitch was distinct in terms of focus and ICTs, there were some recurring themes as well, among them the use of crowd/outsourcing, reliance on mobile devices and pilot projects planned in India.

Here, in alphabetical order, are brief descriptions of each company, pretty much verbatim from their pitches, along with contacts in case you're interested.

1. AwaazDe’s primary offering is a voice messaging platform that allows individuals to call a hotline, leave a message, and receive a tailored response from the organization managing the hotline. Team: Paul Goodman, Meena Natarajan, Rose George.
2. Edumile enables micro-loans through social investors to reach students pursuing higher education in India. Team: Satish Polisetti, Ankita Goyal, Sean Carey.
3. Mobile Works gives underemployed and impoverished individuals in the developing world the ability to earn supplemental income by doing work through their mobile phones. Team: Anand Kulkarni, Daniel Chiang, Philipp Gutheim, Prayag Narula, David Rolnitzky.
4. The NGO360 web directory is a website for NGOs and anyone interested in learning more about them. The profiles serve as a hub for discovering more information about NGOs in existing web locations. Team: Walter Koning
5. Shreddr revolutionizes data management by providing organizations with on-demand paper data transcription and access to digital versions of their data. Team: Andrea Spillmann, Ariel Chait, Daniel Perry, Kuang Chen

The pitches this year were strong; so strong that we decided to award 2 "first place" prizes ($4k each to AwaazDe and MobileWorks) and a second prize ($2k to Shredder) as well. I know that risks spreading the love too thin to do any one project much good, but I think all the judges agreed that several of these projects have a real chance to get to pilot, and even modest support, however small, can help to leverage additional funding.

I look forward to following their progress and hope to be invited back next year for more great pitches and an update on the alums.

In February 2008, The Health Metrics Network (HMN) convened experts in Geneva after many months of focused organizational, advocacy and educational efforts in several countries.

The goal of the event was to test interoperability of core elements of a district-level health solution that would be repeatable across the dozens of countries in which HMN is currently working.

Inveneo participated in this meeting and what follows is a brief discussion of four key ICT challenges identified by the HMN working group and how Inveneo is seeking to overcome them.

Power Challenges

Lack of consistent and affordable electricity is the single greatest challenge in designing a computing infrastructure for rural health informatics (or any other application for that matter). The vast majority of health facilities in remote parts of the developing world have no mains power and, where available, such power is usually extremely unreliable or so unstable that it poses a threat to unprotected electronic equipment.

Among off-grid health facilities that nevertheless have power, diesel generators are the most common source. But increasing fuel costs and on-going maintenance problems mean that generators are seldom run for more than a few hours a day (often only during medical procedures that require powered equipment) and are prone to abrupt and unannounced failure. Alternatives such as solar panels are simply cost prohibitive when deployed to support standard computing hardware.

Pending the decades long process of extending stable, grid power to remote communities or the advent of an entirely new computing paradigm, the logical immediate answer to this challenge lies in low-power-consuming hardware. Fortunately, hardware now exists that is cost-effective to run on solar (or other renewable) or in partial-grid power.

For example, the Inveneo High-Efficiency Computing Station (PDF) draws just 17 watts of power, compared with 50+watts for a typical laptop, well over 100w for a new desktop and over 150-200w for an older workstation with CRT monitor.

Along those same lines, the Inveneo R4 Hub Server draws under 30 watts, compared with 200w or greater for many new servers.

Due to a number of factors, including increased energy cost, the market shakeup due to the proliferation of mobile platforms, increased focus on "bottom of the pyramid" opportunities, not to mention pressure from Inveneo and other integrators, chip makers are now paying more attention to power efficiency, which should increase availability of processors that can support cost-effective health applications in the developing world.

Efforts are also underway with DHISv2, OpenMRS and other health applications to minimize their system resource requirements and on other ways to improve overall performance on low-power, energy-efficient hardware platforms. This work is a prime example of where closer collaboration between hardware designers and those working on health applications can lead to better integration, repeatability and performance.

Environmental Challenges

The physical environment in most rural and remote settings is characterized by some combination of heat, dust and humidity, each of which is a challenge for standard computers. High speed CPUs generate enormous amounts of heat that, if not properly dissipated, reduces performance or can render these systems inoperable. Dust threatens sensitive electronics by shorting circuits and impeding airflow and heat dissipation. Humidity leads to condensation, corrosion and even mold, all of which can cause electrical problems and possibly shorten equipment lifespan.

Besides reducing power costs, power-efficient computing also helps to resolve these environmental challenges. CPUs with slower clock speeds generate less heat and, with appropriate thermal design, can be deployed without fans. This allows computer enclosures to be better sealed against these threats as well as vermin of various sorts. Fewer moving parts also means greater reliability and lower overall operating costs. In exceptionally remote and/or hot environments, solid-state flash memory can be substituted for hard drives, which are prone to failure in extreme heat and are a common failure point requiring support.

Connectivity Challenges

Lack of affordable connectivity and bandwidth is the primary obstacle to several of the most promising health applications for rural areas, including tele-medicine and other real-time diagnostic support and training initiatives. Lack of connectivity also complicates more basic efforts to collect and analyze health information.

For example, managing electronic medical records for peripatetic patients requires some means of accessing patient information from multiple locations. Similarly, accurate and timely health statistics are extremely difficult to compile in the absence of some form of connectivity, as is managing logistics or other key processes. Finally, lack of reliable connectivity complicates core IT functions, such as systems updates and virus control, thus increasing costs while reducing use value.

Once again, however, tools now exist to overcome these challenges for a growing portion of the communities in questions. The dramatic expansion of cellular networks across Sub-Saharan Africa means that affordable data services are now available for the first time in many areas. Although most cell networks do not yet provide high-speed connectivity (at least not in rural areas), they can support a number of valuable asynchronous and low-bandwidth applications, like email, which are easy to use, powerful and sustainable. As these networks expand and are upgraded, they will provide crucial connectivity for a large number of rural communities and will be better able to support data-intensive applications.

Open protocols, such as WIFI, and durable off-the-shelf products offer an alternative, often complementary, approach. Work done at UC Berkeley in the TIER group's the "WILD" project and elsewhere has adapted the core protocols for WIFI to allow increased bandwidth over long distances. And equipment maker Ubiquti has developed a comprehensive line of durable yet inexpensive WiFi antennas that Inveneo has certified as appropriate for rural wireless networks:

The technology relies on line-of-site, but for less than $1000 it is now quite simple to create a reliable broadband (6mbps) link over distances as great as 100-200km. Such links can be used to extend low cost Internet connections in urban settings to the near periphery at low cost or to share a VSAT connection to multiple facilities in more remote settings.

Even in the absence of Internet service, this approach can support high-speed networking among health facilities to deliver access to shared resources, tele-medicine, tele-training, VOIP telephony or other applications that require higher bandwidth.

Still, while connectivity options are improving, careful design for low-bandwidth and delay tolerance remain critically important. Only systems-level design that accounts for system resource as well as networking constraints can support this objective.

Human Resources and Other Non-technical Challenges

As important as these physical and infrastructural challenges are the many human factor and institutional obstacles to sustainable health information solutions in underserved areas. A partial list of these includes:

• Inexperienced computer users
• Lack of trained technical support
• Absence of defined, action-oriented health indicators
• Uncoordinated or absent governance mechanisms
• Inadequate oversight and/or incentives for health workers
• Widespread poverty and associated security risks

It's worth noting that to succeed health information solutions for rural and remote environments must accommodate inexperienced computer users and novice administrators, not visa versa. This is true both for usability and resiliency. In settings where users may be encountering a mouse and keyboard for the first time, an intuitive and simple interface are critical - "less is more."

Health Information Stakeholders Meeting: Kono District, Sierra Leone

Even when users are more sophisticated, lack of qualified on-site (or even in-district) technical support means that systems must be "hardened" against not just the physical environment but against user error as well.

One way to do this is to "lock down" the file system of the computers so that users cannot inadvertently delete system files or install viruses or other malware. If the system does somehow become mis-configured or infected, a simple on-off cycle will return the machine to its originally configured state.

Server software can include similar controls that streamline and simplify the process of configuring and managing workstations and system resources connected to a local or wide area network.

Conclusion

Itis increasingly clear that information is the lifeblood of a healthcare system. Accurate, timely and accessible health information strengthens literally every part of the system, from policy making, to clinical treatment, to logistics and training. In contrast, inefficient health information systems suffer from an informational anemia that weakens the entire system.

Sadly, all too many health systems in the developing world still suffer from the equivalent of information shock; a system-threatening condition characterized by the inability to generate, access or act on even the most essential health information.

Success or failure of ICT deployments in rural healthcare depends on access to affordable, integrated solutions that are both sustainable in low resource settings and customizable to local conditions. Inveneo is actively developing and deploying such systems specifically to address this need.