Field Survey Report for

the Global South e-Health Observatory

Meeting with MoSQuIT (India)

MoSQuIT team in project offices in Pune, C-DAC

Samir Abdelkrim (April 2018)

Genesis of the project Here we are in the Indian city of Pune, one of the main cultural, historical but also

technological hubs of India, in the state of Maharashtra. With 3.75 million inhabitants, Pune

is the 8th most populous city in India. The rickshaw stops in full sun in front of a modern

building. We are in front of Centre for Development of Advanced Computing (C-DAC), the

research center specializing in Advanced Computing. Originally created in 1988 to develop the

first Indian supercomputer at the end of the Cold War, C-DAC has evolved significantly in its

mission to become a leading R & D center leader in India specializing in designing and

developing digital solutions.

Under the auspices of the Indian Ministry of Electronics and Information Technology, C-DAC’s

mission is to carry out research to make use of digital technology for human advancement

including Health informatics. This is particularly the case for the MoSQuIT research program:

an initiative that aims to reduce the impact of malaria on the most vulnerable populations by

helping the country's health authorities to contain and better anticipate epidemics in rural

areas of India. The government entrusted C-DAC with the mission of experimenting with new

solutions through mobile technologies. Thus the MoSQuIT project was born to fight against

the lack of knowledge of society about malaria, and to eradicate epidemic foci mainly located

in the Northeast region of India, in collaboration with Regional Medical Research Centre

(RMRC)/ Indian Council of Medical Research, Dibrugarh, India.

I am picked up on the second floor of C-DAC by Lakshmi Panat, who is the MoSQuIT project

Joint director, and her entire team. Among them domain expert doctors like Dr. Ganesh

Karajkhede, and mobile developers are working on the MoSQuIT application. Lakshmi Panat

begins by giving me some key figures on the mobile application. MoSQuIT was established in

2014 and is used mainly in the isolated states of Tripura and (especially) Assam, both located

in Northeast India. Very heavily landlocked between Bangladesh and Burma, very difficult to

access (members of the MoSQuIT project team explain that it takes an average of 2.5 days

to reach Assam, both in and out), Lakshmi Panat explains: “in the remote villages of

Assam, malaria endemicity is higher than the average in the rest of the country”.

The MoSQuIT application during a demonstration by a member of the team

What is MoSQuIT? How does the system work?

Created in September 2014, MoSQuIT is an application for monitoring and preventing malaria

epidemics. It now has over 170 direct users in the following categories:

● The first category of users of the MoSQuIT application are the health workers,

called ASHA, who are located in the rural areas of the state of Assam and

recently in the state of Tripura. The acronym ASHA is from Accredited Social

Health Activists. They are the points of contact between the C-DAC teams and the

living populations in the rural areas concerned. They are trained in two days by C-DAC

team along with RMRC team to use the application on a smartphone or tablet. Once

trained, their mission is to find traces of malaria in remote villages, making many field

visits. They carry out the blood samples used to carry out the malaria

detection test in the primary health centers, collect and record in the

application the maximum of information on the identified sick persons.

ASHA collect data in the field in a remote village in the Assam region

Sudhanshu Debnath, MoSQuIT project leader explains to me that I went to Assam and Tripura

along with RMRC team to train ASHAs in partner health centers. He mentioned at our working

meeting that last month that the team trained about 32 ASHAs in a primary health center

located in the state of Tripura, and 18 ASHAs in the State of Assam, about usage of the

MoSQuIT application.

ASHA training on the use of the field application in the Assam region

● The second user category of the MoSQuIT application is the "Laboratory

Technicians" as well as the "Medical Officers" located in the partner health

centers located in the States concerned. The primary care centers partners are

5, they cover more than 50 villages, which represents more than 50,000 inhabitants in

Assam during pilot phase. Laboratory technicians perform microscopic

examinations collected by ASHA, confirm malaria cases.

● The third category of users are finally the epidemiologists of the Indian Council

of Medical Research which is a partner and beneficiary of the MoSQuIT project, and

also Medical Officers: they can, through the application, generate epidemic reports

based on the data collected by the ASHAs and updated by the "Laboratory technicians",

raise awareness and make recommendations to regional and national health

authorities.

The data analysis phase with the MosquIT application

To summarize: the ASHAs collect the field information in the different villages that are sent to

the application server. The "Laboratory technicians" as well as the "Medical Officers" then

connect to the application to download and analyze the data collected. They send the results

to the application. The epidemiologists of the Indian Council of Medical Research and “Medical

officers” generate reports on the basis of all the data, for example on the whole of one or

more villages which allows them to have an overview. In view of the overall results, the

epidemiologists of the Indian Council of Medical Research/ “Medical officers” can

detect the risks of epidemics and issue alerts throughout the State public health

system.

Video conference in progress with the medical team based in Assam

We are conducting a videoconference with the medical team of Assam, which works in contact

with the populations, under the leadership of Dr Saurav Patgiri, accompanied by Mr S K

Goswami. After several unsuccessful attempts, the Internet connection - weak - is finally

established. I discussed the obstacles and challenges encountered in the field. The

local team explains to me that the connectivity, of poor quality and random in the rural areas

of the North-East, is one of the main problems. And that some ASHAs, who are often illiterate,

often have difficulty integrating data collection protocols into samples. “This is because

many use a smartphone for the first time in their life” Explains the Assam team. In

addition to the fact that 99% of the territorial borders are international (the North East region

is bordering with Bangladesh, Bhutan and Burma), and majority of the territory is inaccessible

by rail and airway. Internet connectivity is particularly low and intermittently

available, which sometimes leads to delays in uploading data collected by ASHA to MoSQuIT

servers. The young ASHA workers are enthusiastic to learn usage of MoSQuIT mobile

app.

ASHA sensitization and training session in the Assam region

What are the health impacts and benefits?

The application now allows to track and treat nearly 200 new patients each month. For

laboratory technicians at primary health centers, the time savings are enormous: they can

transmit the results to the application instantaneously instead of 21 days on average with

the data collection method on paper.

For epidemiologists/ “Medical officers” at the Indian Council of Medical Research, one hour is

sufficient to obtain a full epidemiological report from the database, compared with 30 days

on average with the traditional paper-based data collection method. On the basis of the

results reported by MoSQUIT epidemiologists, the Indian Council of Medical Research can very

quickly trigger epidemic alerts. This makes it possible to forecast stocks of antimalarial

drugs upstream, to allow pharmacies to receive stocks on time and to trigger emergency

measures upstream in terms of public prevention policies.

Thanks to the collection made via MoSQuIT the time gains are impressive and the transmission of instant information

The application's functionalities help national and regional health authorities to better

anticipate epidemic crises thanks to the predictive analysis enabled by the MoSQuIT

technology tool. In just a few minutes, epidemiologists can generate reports of evolutionary

trends in epidemiological observations based on a given period (from 1 month to

more than 3 years of history), geographical location or sociological characteristics

of the patients followed. The application allows in particular to generate in a few minutes

annual statistical indicators in the regions covered such as the annual incidence rate of

Falciparum, annual mortality rates, annual infection rates by age group, etc.

In case of epidemic alert, information can be sent to other health centers by e-mail or SMS

What about financing and the business model? The application is completely free, so there is no subscription fee model. The

main costs of the application are represented by the server's hosting costs, the

purchase of mobile phones which are then redistributed on the ground to the ASHAs,

the purchase of communication and internet package for the ASHA, the field trips for

the realization of training as well as the trainings themselves which last on average

two to three days (rental of training places, accommodation, food, as well as the

remuneration of ASHA. For the moment, the MoSQuIT project is funded by C-

DAC, and Indian Council of Medical Research for development and deployment. The

MoSQuIT project also benefited from external recognition received by

winning numerous awards and competitions such asthe Open Group 2018

competition prize, the e-Assam Challenge 2015, the 5th e-North -East

Technology Award Summit 2014, the mBillionth Technology Award, the SKOCH

Group's Order of merit.

Which partnerships are relevant for MoSQuIT? The C-DAC is currently seeking to strengthen its links with the national health system and

private Internet companies capable of providing them with new and efficient infrastructures

(cloud, internet providers, mobile technology and device). C-DAC also wants to collaborate

with more epidemiologists, and through its strong links to public digital policies, C-DAC strives

to push the MoSQuIT project and the issue of fighting epidemics through government digital

initiatives, such as the Digital India initiative led by the Indian government.

The MoSQuIT project has won numerous awards and competitions in the last 3 years

Conclusion A powerful technological solution targeting the poorest and most isolated Indian populations

living in hard-to-reach areas and proven in Tripura and Assam States. MoSQuIT has a path-

breaking impact due to the speed of data processing and its great ability to predict real-time

outbreak risks. C-DAC has the ambition to scale up by expanding the surveillance

system for malaria to other diseases, like AIDS, dysentery, Dengue fever or

Japanese encephalitis. C-DAC is open to replicating MoSQuIT's technology to other

countries, including South Africa.