Improving Rural Healthcare Deliveryvia Transparent Monitoring

Bill ThiesMicrosoft Research India

In collaboration with Manish Bhardwaj1,2,Sara Cinnamon2,3, Goutam Reddy2,3, Emma Brunskill1,2,

Somani Patnaik1,2, Seema Kacker1,2, Sourav Dey1,2 and Ajit Dash1,2

1Massachusetts Institute of Technology2Innovators In Health

3Abiogenix, Inc.

MEDITEL / December 20, 2008

Microsoft Research IndiaEstablished January, 2005

Seven research areas– Algorithms– Cryptography, Security & Applied Math– Digital Geographics– Mobility, Networks, and Systems– Multilingual Systems– Rigorous Software Engineering– Technology for Emerging Markets

Contributions to Microsoft:– MultiPoint, Netra, Virtual India

Currently ~55 full-time staff, growing

Collaborations with government, academia, industry, and NGOs in India

Microsoft Research IndiaSadashivnagar, Bangalorehttp://research.microsoft.com/india

“Technology for Emerging Markets”

Understand potential technology users in developing communities

Design and evaluate technology and systems that contribute to socio-economic development of poor communities worldwide

Collaborate with development-focused organizations for sustained, scaled impact

Computer-skills camp in Nakalabande, Bangalore(MSR India, Stree Jagruti Samiti, St. Joseph’s College)

Research Group Goals

Multidisciplinary ResearchAishwarya Lakshmi Ratan

–Public Administration and International Development

Jonathan Donner

– Communications

Nimmi Rangaswamy

– Social Anthropology

Indrani Medhi– Design

Kentaro Toyama (Group Lead)

– Computer Science

Society

Group

Technology

Individual

Society

Group

Technology

Individual

Innovation

Understanding

Impa

ct

Innovation

Understanding

Impa

ct

Rikin Gandhi– Astrophysics

Bill Thies - Computer science

Saurabh Panjwani - Computer science

David Hutchful– Human Computer Interaction

Kelsa+

Microfinance & Technology IT and Microentrepreneurs

Information ecology of very small businesses

Potential of technology to support microfinance

MicroenterprisePC + mobileMixed-method studyResearch only

Text-Free UI

Text-free user interfaces fornon-literate users

User interfacesPCDesignUser studiesGuidelines

MicrofinancePC + mobileQualitative studiesBusiness analysisResearch only

Sample Projects

Information accessPCQualitative studyUsage analysisPilot

Featherweight Multimedia

Paper and cheap electronicsfor low-cost multimedia

General educationElectronicsHCIUser studiesPrelim research

Simultaneous Shared Access

Primary educationPCHCIUser studiesSoftware SDK

Warana Unwired Digital Green

Video and mediated instructionfor agriculture extension

Substitution of mobile phones for rural PC kiosks

AgricultureVideoInterventionControl trialsPilot

Info systemsMobileInterventionRural kiosksPilot

Free access PCs for low-income office staff

Multi-user systems for educational

6

Drug Delivery: Last-Mile is Often Broken

TB treatment: 4 drugs, 6-8 months Worker supervises ingestion

3 times/week (DOT)

Rural programs operate in the dark Interaction: Are workers reaching patients? Adherence: Are patients taking medication? Health: Are patients getting better?

Mission: Track Interaction, Adherence, Health

DrugDevelopers

DistributorsRural

PatientsLocal

Clinics

Courtesy PIHCourtesy PIH

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The uBox: A Smart PillboxDeveloped by Abiogenix, MIT, and Innovators In Health

The uBox monitors Delivery, by logging worker visits Adherence, by logging pills dispensed

uBox impact Worker supervision and incentives Timely and targeted intervention Lowers adherence burden

uKey(for worker)

uBox(for patient)

Patients Workers Clinic

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Workerenters vital patient healthindicators into cell phone

Nurseanalyzes data,

identifies problems

Physician sends advice to patients,

schedules field visits

Patientlives in a remote area

The uPhone: Monitoring Patient Health

9

Is Technology Really the Answer?

Often ignores systemic and societal issues But, delivery is overwhelmingly about diligence

Today: 2.4M doses/day, 187 countries, 77% reliability Need: 7M doses/day, 100% reliability FedEx: 7.5M shipments/day, 220 countries, 97.7% reliability

Our goal is to reduce the burden of diligence Change the culture: 85% is not enough Need to respond to every failed transaction Identify superstar workers early and replicate techniques

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uBox Training

• Class was proficient in < 3 hours• Overcame prototype shortcomings• Gave very good suggestions

Bihar, Spring 2008By MIT and Innovators In Health

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uPhone Training

• uPhone more challenging – literacy and prior cell phone experience needed• Lesson learned: - Even with intensive training, many errors on menu-based interface

Bihar, Spring 2008By MIT and Innovators In Health

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Evaluating the Accuracy of Mobile Data CollectionWith Somani Patnaik and Emma Brunskill, to appear at the 2009 International Conference on ICTs and Development (ICTD 2009)

PDAs Cell Phones

Published error rates

Malaria monitoring in Gambia (Forster et al.) Clinical study in Gabon (Missinou et al.) Tuberculosis records in Peru (Blaya & Fraser) Sexual behavior surveys in Peru (Bernabe-Ortiz et al.) None?

Others

SATELLIFE (Groves et al.) DataDyne EpiSurveyor (Selanikio & Donna) EpiHandy (Engebretsen) Infant health in Tanzania (Shirima et al.) e-IMCI project in Tanzania (DeRenzi et al.) Respiratory health in Kenya (Diero et al.) Tobacco survey in India (Gupta) Ca:sh project in India (Anantraman et al.)

Cell-Life in South Africa (Fynn) Jiva TeleDoc in India (UN Publications) Pesinet in Mali (Balancing Act News) Malaria monitoring in Kenya (Nokia Newsletter) Voxiva Cell-PREVEN in Peru (Curioso et al.)

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1. Electronic Forms Interface

14

2. SMS Interface

15

3. Voice Interface

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User Study Gujarat, Summer 2008Conducted by Somani Patnaik, MIT

Evaluated three user interfaces: - Electronic forms - SMS - Voice operator

Results: - Forms error rate: 4.2% - SMS error rate: 4.5% - Voice error rate: 0.45%

Other benefits of voice: - Easy to verify - Easy to replicate - Less expensive

These results caused us to changeour program to use a voice interface

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Conclusions

Potential for simple technologies to offer largebenefits for improving rural healthcare delivery

Low-tech interfaces may be highest-impact uBox provides transparent interface Operator-assisted reporting better than automated SMS, Forms

Most exciting aspects of work coming in next steps Can technology improve health outcomes in controlled trial? Is operator interface effective in practice?

Seeking additional partners!

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Innovators In Health:Ensuring Reliable MedicationDelivery in the Developing World

Community Partner

Sponsors

… and manygenerous individuals!

The Prajnopaya Foundation

Prior Contributors Alex Krull Oliver Venn Jessica Leon Nikhil Nadkarni Catherine Dunn