Making Healthcare More Accessible to Rural Communities In Waslala, Nicaragua Using Low

Cost Telecommunications

P. Singh, E. Keech, B. Mariani, R. McDermott-Levy and J. Klingler

Villanova University, Villanova, PA

Open 2012 – NCIIA Annual ConferenceMarch 22-24, 2012San Francisco, CA

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Outline

Context: health, social and economic parameters

Dimensions of challenge– Human, medical– Technical– Economic sustainability

Progress-to-date Partners Future Plans

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General Challenges

• Poor Infrastructure• Low level of education• Residue of civil war still influences region• Generally low income communities• Language and culture

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Project Context• Initial pilot location: Waslala - region of approx. 50,000

• Central town surrounded by ~90 rural communities

•Rugged terrain

•Neglected by Public Health System

Waslala

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Healthcare in Waslala

Ministry of Health runs regional hospital Only 6 trained doctors serve Waslala + rural

areas Catholic Parish organizes and trains

community health workers (CHWs) to promote health

CHWs– serve their own community– have limited education (as low as grade 2)– are trained by parish to extend reach of medical

services and health information– are volunteers

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Main Hospital in Waslala

Three Dimensions of Challenge

1. Human Factors, Nursing Training

2. Technical Factors

3. Economic Sustainability

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1st Dimension:

Human factors, Nursing Challenge Approx. 90 rural communities 1-14 hours of travel from town (when

possible) Community Health Workers (CHWs)

– Primary healthcare contact

– 2-10 grade education

– Lack basic medical equipment.. thermometers, blood pressure cuffs, stethescopes, etc.

– Need training in normal physiology, using medical equipment,

preventive care, basic health assessments,basic medication, patient follow-up, documentation 8

Immediate Healthcare Goals

Provide rapid, real-time computer-assisted assessment assistance

Develop infrastructure to create, store and retrieve patient records

Equip, educate & train CHWs Obtain accurate baseline data

Set outcome measures to match national goals

– e.g. prenatal visits with skilled professional 2-3 times before delivery

– (hospital) deliveries with skilled attendant9

Medical Equipment, Training

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2nd Dimension: Technical Need technology to reach out to rural

population Few have access to electricity; no Internet

access Cell phone service widely available, although

not everywhere

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Proposed Solution

Equip CHWs with inexpensive cell phones Set up organized system for

– Collecting and transmitting patient information

– Storing and organizing electronic health records

– Health assessments and remote medical advice

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Rural Sites

Remote Monitoring Center

Remote Administration (Villanova)

SMS

Internet

Router

Doctor's computer

Solar Chargers

Solar/Battery Backup Power

MedicalServer

CellularModem

System-Level Block Diagram

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Backup Power Supply

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3rd Dimension: Economic Sustainability

Yearly variable costs (per community) Cost per year

Air time (plan of 1,000 text messages) $120

Replacement of medical equipment* $30

Total variable costs: $150

Yearly fixed costs  

Doctor’s wages $1,800

Technician’s wages $2,500

Total fixed costs: $4,300

One-time fixed costs** (per community) Costs per year

Phone $30

Solar cell phone charger $50

Shirts and ID badges $20

Total one-time fixed costs: $100

*Medical equipment – donated; Communities are responsible for replacement of supplies

**Costs incurred at the beginning of system uptake; avg. equipment lifetime is 3 yrs

ExpectedCosts

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Funding Plan

Operational costs– Community fund overseen by Waslala parish– Individual household contributions

Community leader collects monthly fee of $2 per household

Parish treasurer covers phone, medical or wage expenses from community fund

Parish treasurer will manage funds through parish bank account

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Progress-to-date Teams of ECE, Nursing and Business students and

faculty have made six trips to the site thus far

In-country office staff established

Provided 25 CHWs with diagnostic equipment and training

Provided cell phones and solar chargers to 25 health workers

Installed server and backup power system in parish

Simplified Spanish manuals and text training video produced

Several partnerships established

Doctor brought into team

Some business model concepts established

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Unplanned Challenges

• Personnel Changes• Spam messages from Claro• Turmoil at the Parish• Closing of Internet café in Waslala

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Future Plans Continue to train and equip more CHWs Put program into the “Cloud” Add diagnostics and decision features to

software Maintain emphasis on ultra low-cost Release software under open-source license Measure outcomes of pilot project

-Identify baseline assessment measures Continue to work with communities to

develop and implement a sustainable business model (including exploring mPeso)

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PartnersEstablished Partners:• NCIIA• Connelly Foundation (supports Nursing travel)• Halloran Philanthropies• Parish Health Program in Waslala• Claro• UNI (National Engineering School of Nicaragua)• UNAN (Nursing School in Nicaragua)• Suni Solar

Emerging Partners:• MINSA (Ministry of Health in Nicaragua)• Pro Mujer• Nicasalud (?)• Inter-American Development Bank (?) 20

AcknowledgmentsElectrical & Computer Engineering StudentsCraig Baumer, Arpita Kothari, Brendan McCoy, Andrew Robinson, Peter Shaw, John Beyer

Nursing StudentsRebecca LaMarca, Fruna Lara, Caitlin Krenek, Katie Weatherbie, Alexandra Reo, present senior nursing students, Tracey Desjadon

Business StudentsDerek Ferguson, Christina Radossi, Tyler Weinrich, Tara McHugh, Alejandro Avellana

Arts and Science StudentCarolina Wolnicki

UNI Faculty and StudentsMaria Virginia Moncada and Carlos Ruiz

UNAN Faculty and StudentsMiguel Estapinon and Yolanda, and others

National Collegiate Inventors and Innovators Alliance (NCIIA)Sustainable Vision Grant Funding

Halloran Philanthropies

Claro

Tim Hansell21

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Thank you!

Backup Slides

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1st Dimension:

Human factors, Nursing ChallengeIdentifying Measurable Outcomes

Nicaragua Profile, WHO (2002) PAHO 2007

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1st Dimension (outcomes contd.)

Inacurate statistics Ministry of Health figures estimated to be 40 – 50% underreported (PAHO 2007)

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Lessons Learned

Human Factors to Consider

– CHWs prefer to remain unpaid volunteers– Teaching first time cell users to SMS is really

hard!– Frequent communication with CHWs avoids

frustration– Keep realistic expectations about project

progress– Motivated in-country project co-ordinators are

indispensable

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Lessons Learned

Technical and Logistics Problems

– Even in major towns, electricity, and Internet connections are unreliable

– Publicly routable IP addresses are the exception, not the norm!

– Even thorough testing using parallel setups does not ensure easy success

– Shopping for simple hardware on-site can take several days!

– Local supplier relationships are essential

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Lessons Learned

Business Hurdles

– Banking infrastructure cannot be taken for granted

– Money moves in mysterious ways– Credit systems are localized and peer-pressure

based– Custodian of funds is essential– Entrepreneurial mindset may be lacking