Mozambique    |  Sub-Saharan Africa

Combining public health and technology to combat Malaria in Africa

Partners: Microsoft Bizspark, Twilio, Chicuque Rural Hospital (CRH), Center of Hope, Drexel University, University of Pennslyvania

Article by: Dhairya Pujara  •   January 2021

Challenge Statement

How might we reduce the rate of mortalities due to Malaria and also create an awareness around prevention techniques?

Background

During my first time in Mozambique from 2012-13, my core responsibilities were helping one of the largest rural hospitals in the districts of Inhambane- Chicuque Rural Hospital. Using my biomedical engineering expertise, I focused on medical devices. I even transported medical equipment roughly worth 20-25,000 USD as part of a donation from my university’s hospital in Philadelphia. When I checked their existing inventory, they already had medical equipment donated from other countries and organizations in the range of 80-100K that was sitting unused. I was wondering why this hospital gets so many donations, when not everyone knows how to use them or fix them in case they malfunction or stop functioning.

Also while researching how rampant the issue was of medical devices not used properly, I came across 2 other important statistics -
1. Health infrastructure is limited; more than half of Mozambicans must walk an hour or more to their nearest health facility, and medicine stockouts are common. There are only three doctors per 100,000 people—a proportion that is among the lowest in the world. 1
2. One of the top 5 leading causes of death in the country, specially for infants and children under the age of 5 is Malaria. 2

The Story

I learnt a lot about Malaria in the process of understanding the complex nature of the public health crisis in Mozambique which could be used in understanding and estimating situations in other Africa countries. After coming back to USA, I launched a 48 hour hackathon event called Impactathon in May 2014 where we invited participants from local universities like Drexel University, University of Pennsylvania, Temple University to create scalable, easily reproducible, cheap, tech solutions to solve some of the issues in African countries. The event was designed for students to use Design Thinking for understanding the complex social problems and using their technical skills to build solutions. The winner of this event would get a partial scholarship to travel to Mozambique in the following year and implement their solution on ground using the help of our sponsors like Microsoft Bizsparks, Twilio and other mentors that we signed up for this event.

And we had a winner in the form of 3 Information science senior year students creating an SMS based app that allows people to request a Malaria test from a community health worker at their doorstep. The solution was simple to use, but not as simple to build. It won the first place, because it had the potential to make the highest impact and it was able to tick off all the boxes for designing a truly human centered public health solution.

The Process

We spent 9 months post hackathon in developing the app, the game plan for implementing this and we would have weekly meetings with Miguel in Mozambique to make sure we can take in his inputs during the design phase. When we finally arrived in Mozambique in March 2015 to implement the SMS app, the ground reality hit us. We realized we missed out on many things that would stop us from implementing our technology in the community. So we used one of the most important tools for community based developmental work: Ethnographic research.

Ethnographic research: This is not just a tool to collect data. It's an opportunity to observe, collect, understand, empathize and reflect upon the stories of people's lives in a community. You do not use this tool to sell more stuff, you do it to truly get a perspective on what it feels like to live in this community. What, Why and how do they make the choices that they do?

If you are unfamiliar with Ethnographic research, check out this under 2 minute sound byte by Erika Hall from Mule Design talking about Minimum viable ethnography. What is the absolute 1 question you would want to ask in an ethnographic research?
InVision · Erika Hall (Mule Design): Minimum viable ethnography

empathy

Ethnography is a technique drawn from anthropology. In this case, the social innovators, designers and the researchers immerse themselves in the community they intend to design the solutions for. But combining ethnographic research with design thinking, you do not just design the solutions for the people but with the people. This can lead to rich insights and stories that can allow a complex social problem to be solved.
As a process of this, we learnt they all have access to 3 things
1. Access to a cell phone, most likely without an internet connection, not a smartphone
2. Access to a can of coca cola
3. Access to a place of worship or a religious institution
This was a very interesting breakthrough. Even though I lived in this community for a few months. I never noticed so carefully that yes, these 3 things were everywhere. The first thought was What does this mean for us? How do we design a solution that revolves around these things? Continue reading the story to find out how our team of designers, students were able to benefit from these insights to design not one, but several solutions in context of malaria and other public health issues in Africa.

research to action

Immersing in the community
We started attending bi-weekly meetings with community health workers. We met with doctors, nurses and the local ministry of health. We learnt that the problem of Malaria not only affects healthcare but the economic fabric of these communities. The known solutions had been
1. Distributing of Insecticides treated mosquito nets ITIN
2. Getting on antibiotics and other prescribed medications
3. Use of Rapid diagnostic testing kits and creating a clear plan involving community health workers and nurses on how to use them 3
The emergence of drug-resistant parasites poses one of the greatest threats to malaria control and results in increased malaria morbidity and mortality. Artemisinin-based combination therapies (ACTs) are the recommended first-line treatment for uncomplicated P. falciparum malaria and are used by most malaria endemic countries. Antimicrobial resistance (AMR) is a global health and development threat. It requires urgent multisectoral action in order to achieve the Sustainable Development Goals (SDGs). 4

Customer Journey
1. Register community health workers in every village
2. Register people in every village
3. Whenever they face symptoms for more than 2 days, they can send a message to a central number and request an RDT at their homes
4. The message is sent to a local community health worker - CHW
5. The CHW comes to your doorstep, gives you a test and logs the result in the system via SMS. If positive, you get the medication immediately from CHW with instructions on how to take them. If negative, the CHW sends in your condition to the doctor for further consultation.
6. The system sends an automatic follow up message to check with patient’s condition and the nearest hospital handles the case from there on, if there is a need for further medical intervention.

Twist in the Tale
This seemed like a straightforward journey. In fact we made this in consultation with our local contacts. Except for there one problem. One big problem. Not everyone knew what the actual symptoms of Malaria are and when to send the message. So we went back to the drawing board and used the Ethnography tool again. This time we lived with the community. We noticed another small part of this subculture. They were used to playing card games to pass time. So we thought of exploring that route, of creating a card game to let them learn about prevention and symptoms of Malaria. This is called community based participatory research.

Community-Based Participatory Research (CBPR) is a research methodology which includes the participation of those who are affected by the issue or problem being studied for the dual purpose of creating knowledge and social change. You can learn more about CBPR here.

when community members are invested in the processes and products of research, dissemination and use of findings occur at higher rates within the community.

the way forward

There were evening after-school gatherings of volunteers who wanted to work in helping us figure out this problem and co-create a solution. A very interesting theme was emerging for how people would draw a mosquito, a bed, a person, and so on. Here are some of the pictures of the work that was produced at these sessions. The core principles of designing and co-creating this solution were
1. Cheap and Affordable
2. Easily scalable
3. Sustainable
4. Collaborative
5. Locally made

Now that we had set in motion, solving the problem of people learning about the symptoms of Malaria, we had to get back to our solution - Ola Health. In the next 2 years, we saw 3 villages using our SMS service to reach out to local CHWs seeking testing kits for malaria. But the best part about collaborative design and having the community invested in the process of designing the solution, they can help you adapt and scale the solution to other uses such as providing information on prenatal care to mothers, scheduling maternity care visits for midwives and expecting mothers and so on. The public health tech app benefited from the cloud credits provided under the Microsoft Bizsparks program for startups. This project was completed in 2017-18 in Mozambique. It taught us about the importance of Design thinking and how a multidisciplinary approach to problem solving can help you build simple robust solutions creating a positive impact in the community.

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