The bridges.org IICD Case Study Series on ICT-Enabled Development sets out to illustrate how information and communication technology (ICT) contributes to development in Africa. The aim of this series is to help ground level initiatives imagine the possibilities of what can happen if they use ICT successfully to overcome development obstacles, and to contribute to the existing body of knowledge on the digital divide.

I. Overview

Initiative: The goal of the SATELLIFE PDA Project was to demonstrate the viability of handheld computers -- also called Personal Digital Assistants or PDAs -- for addressing the digital divide among health professionals working in Africa.

Implemented by: This project was inspired and led by SATELLIFE, a non-profit 501(c)(3) organisation based in Massachusetts, USA. SATELLIFE's mission is to improve health in the world's poorest nations through the innovative use of ICT. It promotes the use of appropriate, affordable technologies to link health professionals in developing countries to each other and to reliable sources of information, including by using geostationary satellites, modem-to-modem telephone links, and the Internet. SATELLIFE worked on this project with a number of ground level partners, including the American Red Cross; Makerere University Medical School in Kampala, Uganda; HealthNet Uganda; Moi University Faculty of Health Sciences in Eldoret, Kenya; and the Indiana University Kenya Program.

Funding or financial model: The project was funded by the Acumen Fund. Acumen brings a new and unique approach to development aid, which focuses on the accountability of project proponents to investors. Acumen identifies high-impact social organisations (both for-profit and non-profit), connects them to philanthropists who want measurable social results for their investment, and measures the result of the impact.

Timeframe: The project took place during December 2001 to December 2002.

Local context: : In Uganda 35% of the population lives below the poverty line. The GDP of the country is US$29 billion and the per capita income is US$1200. An average desktop computer costs approximately US$1000-1300, and a laptop computer ranges from US$1300 to $2200 (for modern, but not state-of-the-art hardware). In Kenya 50% of the population lives below the poverty line. The GDP of the country is US$31 billion and the per capita income is US$1000. An average desktop computer costs approximately US$1425 and a laptop costs approximately $2000. Overall, ICT access is low in both Uganda and Kenya in terms of telephones, computers, and other basic infrastructure; however both governments are working to improve the situation. PDAs are virtually unavailable in Uganda and Kenya. ICT access is also low overall in the healthcare environments of Uganda and Kenya, although it is clearly higher than the national average. All of the major hospitals and the medical schools visited used computers for administrative purposes, but only in limited ways. For the participants in the study - and presumably also the future users of PDAs in developing countries - limited access to landline telephones and/or PCs affected their use of the PDA. Since PCs, PDAs and other technologies are not widely used in substantive applications in the healthcare field in Uganda or Kenya, it follows that no country-specific healthcare information was available which was also ready-to-use with a PDA.

The development problem/obstacle addressed: Healthcare is one of the leading issues affecting African development today. HIV/AIDS is devastating the continent, and that is only one aspect of the healthcare crisis. For example, malaria is by far the most lethal tropical parasitic disease, killing more people than any other communicable disease except tuberculosis (TB), and it is estimated to have cost Africa USD $100 billion over the last 30 years[1]. Yet malaria, TB, and other diseases can be managed if promptly diagnosed and adequately treated, and in many cases prevention methods are relatively cheap and simple. But lack of information on treatments and disease management is often an underlying issue that hinders effective patient care and prevention.

Information and communications technology (ICT) can play an important role in combating disease and improving healthcare. ICT can be used as a tool for collecting community health information to support decision-making; improving doctors' access to current medical information; linking healthcare professionals so they can share information and knowledge; and enhancing health administration, remote diagnostics, and distribution of medical supplies. But even though ICT can help, the solution to Africa's healthcare crisis is not as simple as installing computers in every hospital and clinic and linking them to the Internet. Infrastructure and hardware mean nothing if ICT is not used effectively because it is not appropriate to the real needs of healthcare professionals at ground level, there is no locally relevant content available, healthcare providers are not trained to use it, or they cannot afford to use it.

How ICT is used to overcome the problem: The SATELLIFE PDA Project explored questions related to the selection and design of appropriate, affordable technology and locally relevant content for use in African healthcare environment, specifically targeted at assessing the usefulness of the PDA for (1) data collection and (2) information dissemination. Physicians, medical officers, and medical students tested the PDA in the context of their daily work environments in order to gain a perspective on the real issues that affect the adoption of technology.

The PDA used was the Handspring Visor Neo, with a 33 MHz DragonBall VZ microprocessor from Motorola, a Palm operating system (Palm OS), and 8 MB of main memory. Pendragon Forms v3.1 was the software program used to create the survey forms. Country-specific drug lists and treatment guidelines were obtained by SATELLIFE in hard copy or electronic formats and adapted to a PDA-accessible format. Medical texts were obtained from Skyscape.

The Project was conducted in three phases. SATELLIFE first put the handheld computers to use for field surveys, by linking this project to a widespread measles immunisation campaign being conducted in Ghana by the American Red Cross (ARC) in December 2001. The SATELLIFE-ARC joint effort used 30 PDAs in a short-term survey intended to determine the efficacy of the measles immunisation campaign outreach efforts and collect some baseline health information. The Uganda phase tested the use and usefulness of 40 PDAs by medical practitioners to conduct an epidemiological survey on malaria, and to access and use medical reference tools and texts. The Kenya phase tested the use and usefulness of 40 PDAs by students to collect field survey information, and to access and use medical reference tools and texts as part of their studies.

The project validated the use of handheld computers in healthcare environments in Africa. There were a number of valuable lessons gleaned from the project that can be applied to further deployment of PDAs in developing countries. A number of obstacles to technology use have also been identified, which will need to be overcome in order to promote the widespread adoption of the technology in this context. Finally, the project has served to open the door for a number of opportunities that are worthy of the attention of technology companies and content providers.

Next steps: Given ground level realities in Africa where electricity, security, and cost are only a few of the factors that inhibit technology use, it is unrealistic to imagine that technology could be put in the hands of the general public if that means a PC in every home or office. But PDAs are a viable alternative that can be used for a variety of practical purposes throughout society, and they may represent a turning point in the way that the digital divide is approached across Africa and beyond. SATELLIFE intends to continue building and implementing projects that will tap the enormous potential of handheld computers to help bridge the digital divide in Africa and beyond.

Geographical area targeted: Ghana, Uganda, and Kenya

Contact Information:
SATELLIFE
30 California Street
Watertown, MA 02472, USA
Tel: + 617 926 9400
Fax: + 617 926 1212
Email: info@healthnet.org

II. Gauging Real Impact

This section considers whether and how the Satellife Project has made a Real Impact at the ground level by looking through the lens of basic best practice guidelines for successful initiatives. The bridges.org's 7 Habits of Highly Effective ICT-for-Development Initiatives are used here as a framework to highlight what the Satellife Project has done well.

The 7 Habits of Highly Effective ICT-for-Development Initiatives

1. Implement and disseminate best practice. It is widely recognised that ICT can play an important role in combating disease and improving healthcare by aiding the collection of community health information to support decision-making; improving doctors' access to current medical information; linking healthcare professionals so they can share information and knowledge; and enhancing health administration, remote diagnostics, and distribution of medical supplies. SATELLIFE carefully examined the use of PDAs in healthcare in the United States, and built this project on knowledge gleaned from the successful experiences of others.

SATELLIFE engaged bridges.org to conduct an independent evaluation of the PDA trial that looked at the technology itself, the content loaded on it, and the impact that the PDA had on the behavior of health professionals and the quality of care they delivered. The evaluation report presents the lessons learned in this project to inform decision-making about future uses of PDAs and other ICT for development. It also provides resource materials for planning and implementing future steps in the SATELLIFE project or related initiatives. The full evaluation report is available at http://www.bridges.org/satellife.

2. Ensure ownership, get local buy-in, find a champion.The project connected with local implementation partners in order to ensure local ownership and buy-in. The American Red Cross was the local implementation partner that linked the PDA project with a broader measles immunisation programme underway in Ghana. The Uganda phase of the project was implemented in cooperation with Makerere University Faculty of Medicine. Professor N.K. Sewankambo, Dean of the Makerere Faculty of Medicine, acted as a main point of contact and local champion for the project. HealthNet Uganda, located at Makerere, acted as a local implementation partner and a full-time SATELLIFE project field manager was based there to coordinate implementation at ground level. A HealthNet Uganda site coordinator provided technical support and project assistance. In Kenya, the project was implemented in cooperation with Moi University Medical School and the Indiana University (IU) Kenya Program. Dr. B.O. Khwa Otsyula, Dean of the Moi Faculty of Health Sciences, acted as a key point of contact and local champion for the project. Moi staff members worked together with the IU Kenya Program to handle local implementation. The SATELLIFE field manager in Uganda also travelled frequently to Kenya and helped to coordinate implementation.

3. Do a needs assessment. This project responded to a need for better information to improve medical treatment and disease management in developing countries. PDAs are widely used in the medical profession in the developed world, but are a relatively new technology in Africa, and little work has been done before now to demonstrate their utility as a tool for healthcare in developing countries.

4. Set concrete goals and take small achievable steps. The pilot was divided into three distinct phases to make it more manageable. The first phase of the project took place in Ghana in December 2001. The Kenya and Uganda phases were conducted in parallel during March-December 2002. SATELLIFE plans to build on this pilot with future projects using handheld computers for healthcare in Africa.

5. Critically evaluate efforts, report back to clients and supporters, and adapt as needed. SATELLIFE and its project partners carried out a series of mid-term evaluations on this project, which were taken into consideration by bridges.org as part of its overall project evaluation. A number of key lessons learned were gleaned from these evaluations, and SATELLIFE and its partners introduced a number of appropriate changes during the project to overcome the identified challenges. SATELLIFE issued regular project updates (at approximately 3-month intervals) to keep clients and supporters current and involved.

6. Address key external challenges. As part of the pilot a number of external challenges that affected the current and future use of the PDAs in these healthcare environments were identified, including bureaucratic hurdles, technology problems, lack of local technology supply, project management issues, and overall project implementation challenges. SATELLIFE is taking steps to tackle these external factors head-on as it moves forward in this area.

7. Make it sustainable. Handheld computers proved to be an inexpensive alternative to PCs in terms of computer power per dollar. In an environment where PCs are beyond the reach of most people, even healthcare professionals, the PDA offered a reasonably priced alternative that gave significant computing power for the price. However, the cost of the PDAs may still be too high for the average person in Africa. The biggest challenge for the technology is whether average people in developing countries will be able to afford PDAs. There is a significant potential market for affordable handheld technology in the developing world, where there is little ICT infrastructure and a lack of conventional ICT such as PCs. The high uptake of cellular telephones in countries such as Uganda, Kenya and South Africa is an indication that people in developing countries are willing to spend money on technologies that prove to be really useful and relevant to them. The industry should produce a cheaper PDA that is targeted to poorer markets. There is clearly a market opportunity for handheld computers in African countries.

III. Lessons Learned

We invited Holly D. Ladd, the executive director of SATELLIFE, to share her views on the greatest success of the PDA Project, the challenges they have faced, key constraints and dependencies that affect the initiative, opportunities for future improvement of what they do, and other lessons they have learned. This is what she had to say:

"Our primary goal for this project was actually quite modest: to test the viability of the handheld computer in rural and urban settings in Africa. But the potential implications were quite profound, especially for the health sector. If our hypothesis was correct, then we would have identified a relatively affordable, portable, and easy-to-use solution to many of the continent's information dissemination and data collection needs.

As it turns out, our hypothesis was correct. The units worked well in a variety of settings, users with little or no previous computer experience adopted the technology quite easily, the health content we provided was enormously valuable, and data collection and analysis was accomplished quickly, easily, and at a fraction of the cost of traditional pen-and-paper surveys. Good end-user training and careful selection and adaptation of content were key requirements for success. The power supply issue was and will remain a challenge until solar power becomes an option, so people need to think carefully and creatively about that when designing projects.

Our philosophy is that there is no single technology solution that will meet all the data and information needs of our constituents in the health sector, but we feel very confident encouraging people to give handheld computers serious consideration as they assess their specific needs. What we have accomplished so far is just a glimpse of what we think this technology can do, and we are eager to keep pushing in new directions."

IV. The Story

In Africa measles are often called the "disease of the wind". Every year, the virus moves swiftly through overcrowded schools and closely huddled shacks, killing almost half a million of African children. Now, efforts to stop this killer have received a significant boost from an unlikely source: the handheld computer, a.k.a. a Personal Digital Assistant or PDA.

As many healthcare workers know, effective management of epidemics are crucial to prevent renewed outbreaks and enable the judicious use of limited health resources. This is where PDAs come in handy. Although the Measles Initiative -- which aims to vaccinate 200 million children in 36 Sub-Saharan African countries -- hopes to bring measles deaths to zero by 2005, the close monitoring of the initiative is key to its success. Normally the Red Cross, one of the key partners of the Measles Initiative, uses pen and paper surveys to gather data about the diseases and vaccination efforts. This data is manually entered into a database and analysed to plan follow-up campaigns. However, this process is cumbersome, time consuming, expensive, and prone to human error.

In December 2001 Satellife worked with the American Red Cross to conduct a pilot that tested the efficacy of PDAs for measles field surveys in Ghana. Thirty Ghanaian Red Cross volunteers, trained over a two-day period, had no trouble with the technology, though some of them had never before used a computer. They were able to complete over 2,400 surveys in just three days, where the traditional paper and pen survey method generally yielded about 200 finished surveys. Survey data was turned in at noon on the last day of the pilot; analysis was completed promptly after the data was hot synched into a computer; and a complete report was delivered to the Ghanaian Ministry of Health by 5pm. The entire pilot was completed in less than a week, and the speed and ease of gathering this epidemiological data was unprecedented.

Fired on by this success, Satellife conducted a second phase of the pilot during 2002: this time, they also wanted to test whether PDAs would be useful for the dissemination of healthcare information. They distributed 80 PDAs -- half to medical students in Kenya, and the other half to practicing doctors and medical officers in Uganda. The PDAs were loaded with country-specific drug lists and treatment guidelines for HIV/AIDS, TB, and Malaria, the latest medical texts, field surveys, health references and guides for diagnosing diseases.

Doctors were very impressed by the amount of information that could be stored on the PDAs, and the fact that it was a real time saver. Normally they would visit patients on the wards and then would have to walk back to the library to confirm their diagnosis. The healthcare information loaded on the PDAs enabled them to confirm their diagnosis on the spot. They also frequently used the PDA's medical calculator, which enabled them to accurately calculate drug dosages. Correct dosaging is especially important when treating children, because they vary in size and weight and a high dosage could easily harm them. Other doctors liked the PDA because they could quickly check the side effects of a drug, which was especially useful when they were prescribing unfamiliar drugs.

Although doctors had almost no previous exposure to PDAs they quickly cottoned on to its potential applications for public healthcare. They suggested it should be used to improve regular disease reporting to city and regional medical officials that would strengthen efforts to identify disease patterns and reaction times to public health threats. Doctors suggested that the PDAs would be very useful in rural areas where textbooks are often unavailable. One highlighted patient record-keeping as a critical future use for the PDAs. A few also mentioned that they would like to use the PDAs to communicate with their colleagues, especially to ask for advice about patient consultations.

The doctors' suggestions hinted at the many other potential ways that PDAs could be used in an African healthcare setting and it would serve healthcare department well to take note of their suggestions. The only obstacle that is really standing in their way is the costs of the PDAs. However, if the cost of the technologies could be driven down, not only would it improve healthcare in Africa, but a whole new market could potentially be created modelled on the example of cellular telephones, which brought unprecedented telecommunications access to millions across the continent. Satellife is hoping that their results would be a wake-up call to industry and a glimpse into the untapped markets where technology could make a real difference to people's lives.

[1]According to Medilinks