ICTworks

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.

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.

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