The SATELLIFE PDA Project

****Bridges.org-IICD case study series on ICT-enabled development****

The bridges.org-IICD Case Study Series on ICT-Enabled Development sets out
to illustrate how information 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. To find out more about
this series, or to view other case studies completed, please go to:
www.bridges.org/iicd_casestudies/index.html [2]

This case study consists of four parts: 1.) the "Overview" that provides
basic information about the organisation/initiative, 2.) the "Gauging Real
Impact" section that contains the evaluative component of the case
study, 3.) the "Lessons Learned" section, written by the
organisation/initiative being reviewed, and 4.) "The Story", a narrative
description of the organisation/initiative.

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) organization 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 organizations (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. 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 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: [email protected] [3]

II. GAUGING REAL IMPACT

This section considers whether and how the initiative 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 7 Habits
of Highly Effective ICT-for-Development Initiatives are used here as a
framework to highlight what the initiative 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/ [4].

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
immunization 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
traveled 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 LEARNT

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
adapted 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

This section presents a narrative description of the initiative that
highlights why this use of ICT for development is particularly interesting.

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.
__________________________________

Author: bridges.org
Date: 3 March 2003

About the IICD and bridges.org ICT-for-Development Case Study Series

The International Institute for Communication and Development (IICD) is an
independent non-profit foundation, established by the Netherlands Minister
for Development Cooperation. IICD assists developing countries to realise
locally owned sustainable development by harnessing the potential of
information and communication technologies (ICT). IICD works with its
partner organisations in selected countries, helping local stakeholders to
assess the potential uses of ICT in development. For more information on
IICD: http://www.iicd.org/about/ [5].

Bridges.org is an international non-profit based in South Africa with a
mission to help people in developing countries use ICT to improve their
lives. Its main focus is to enable informed policy decisions, which affect
people's access to and use of ICT. Bridges.org also gets involved in ground
level projects to study the effects of policy decisions and relay lessons
learned to the international development community. It brings an
entrepreneurial attitude to its social mission, and is committed to working
with, instead of against, government agencies and the business
community. For more information on bridges.org: www.bridges.org [6].

This initiative is supported by the Building Digital Opportunities
Programme (www.iconnect-online.org [7]) which is funded by the UK Department
for International Development (DFID), the Directorate General International
Cooperation (DGIS), and the Swiss Agency for Development and Cooperation (SDC).